Prep U- Chapter 10: Principles & Practices of Rehabilitation

The nurse working on a rehabilitation unit rotates a client's forearm so that the palm of the hand is facing down. The nurse documents this as which type of movement? -Eversion -Inversion -Spination -Pronation

Pronation

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate? -"Keep your fluid intake to fewer than 2 liters per day." -"Try to increase your activity level a bit more." -"Eat plenty of fruits and vegetables throughout the day." -"Do not delay the urge to move your bowels when it occurs."

"Keep your fluid intake to fewer than 2 liters per day."

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time? -Upon arising -Around lunchtime -Before bed -After breakfast

After breakfast -Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation.

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk? -Hematocrit, 43.5 -Hemoglobin, 10.5 -Potassium, 3.0 -Albumin, 1.5 g/dL

Albumin, 1.5 g/dL -albumen concentrations <3 g/dL are associated with hypoalbuminemic tissue edema and increased risk of impaired skin integrity related to pressure ulcers

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? -Stop any activity once fatigue occurs. -Emphasize areas of strengths. -Avoid seeking help from others. -Group any heavy work to be done at the same time.

Emphasize areas of strengths.

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding? -Anoxia -Eschar -Hyperemia -Ischemia

Hyperemia -The initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia, which normally resolves in less than 1 hour. Unrelieved pressure results in tissue ischemia or anoxia. Eschar is a dry scab that forms over a healing ulcer.

The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair? -Tilt the chair back when moving the client. -Encourage the client to slide up without assistance. -Lift the client, do not slide them. -Use a donut device while the client is in the chair.

Lift the client, do not slide them.

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? -Physical therapist -Patient -Physician -Nurse

Patient

The nurse is evaluating the serum albumin of a client newly admitted on the rehabilitation unit. The nurse determines that the client's serum albumin concentration is low, indicating that the client has which deficiency? -Phosphorous -Protein -Potassium -Calcium

Protein -Serum albumin is a sensitive indicator of protein deficiency

The nurse is caring for a client with a spinal cord injury who has no awareness of the need to void. The nurse should document that the client has which type of incontinence? -Reflex (neurogenic) incontinence -Toilet incontinence -Functional incontinence -Stress incontinence

Reflex (neurogenic) incontinence -Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void.

In which stage is a pressure ulcer considered a partial-thickness wound? -Stage I -Stage II -Stage IV -Stage III

Stage II -A stage II pressure ulcer is considered a partial-thickness wound

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

Stage III -stage III pressure ulcer, a deep crater with or without undermining of adjacent tissues is noted

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? -Stage IV -Stage I -Stage III -Stage II

Stage IV -stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip? -Protective boots -Range-of-motion exercises -Pillow between the legs -Trochanter roll

Trochanter roll -trochanter roll extending from the crest of the ilium to the mid-thigh prevents external rotation of the hip.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: -advance the affected leg. -advance both legs. -advance both crutches. -advance the unaffected leg.

advance both crutches. -nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is -resistive. -active-assistive. -isometric. -passive.

isometric. -Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position

To prevent footdrop, the client is positioned -in a side-lying position. -to keep the feet at right angles to the leg. -in a semi-sitting position in bed. -in a sitting position with legs hanging off the side of the bed.

to keep the feet at right angles to the leg. -patient is supine in bed, padded splints or protective boots are used. Semi-Fowler's positioning is used to decrease the pressure of abdominal contents on the diaphragm. In order to prevent footdrop, the feet must be supported

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is -passive. -isometric. -active-assistive. -resistive.

isometric. -Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement? -Keeps the head erect while combing the hair -Holds onto the furniture when walking in the house -Uses the handrail on one side to go down the stairs -Lifts one leg by raising it off the ground

Holds onto the furniture when walking in the house

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? -Protein -Zinc sulfate -Vitamin C -Water

Protein -Protein is the nutrient important for overall tissue repairr

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage? -Stage I -Stage II -Stage III -Stage IV

Stage II -stage II pressure ulcer is considered a partial-thickness wound

Rotation of the forearm so that the palm of the hand is down is termed -supination. -eversion. -pronation. -inversion.

pronation. -Pronation is the rotation of the forearm so that the palm of the hand is down. -Inversion is movement that turns the sole of the foot inward. -Supination is rotation of the forearm so that the palm of the hand is up. -Eversion is the return movement from flexion.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply -Toileting -Bathing -Eating -Cleaning -Cooking

-Toileting -Bathing -Eating -ADLs refer to those activities related to personal care

A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply. -inactivity -immobility -vascular disease -dehydration -localized edema

-dehydration -immobility -inactivity

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? -Putting slippers on the client's feet -Crossing the client's ankles every 2 hours -Attaching braces or splints to each foot and leg -Placing hand rolls on the balls of each foot

Attaching braces or splints to each foot and leg -Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment