Tissue Integrity

To help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use which of the following?

A trochanter roll extending from the crest of the ilium to the midthigh

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description?

"Habilitation focuses on the person's abilities."

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?

"I'll eat plenty of fruits and vegetables."

A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. After teaching the family about reducing the patient's risk for skin breakdown, the nurse determines that the teaching was successful when the family states which of the following?

"We need to make sure that the patient drinks enough fluids."

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

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.

Bathing, Toileting, Eating

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

Braden scale

A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize?

Following a regular emptying schedule

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

Hyperemia

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

Incontinence and right-sided hemiparesis

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?

Overall risk of developing pressure ulcers

Which therapeutic exercise is done by the nurse without assistance from the patient?

Passive

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

The nurse is reading the previous shift's documentation of an open area on the patient's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the patient's sacrum will reveal a pressure ulcer in which of the following stages?

Stage II

To prevent footdrop, what is the best way for the nurse to position the patient?

To keep the feet at right angles to the leg

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?

Trochanter roll

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?

patient

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

• Edema • Anemia • Diaphoresis

The nurse is evaluating the lab values of a patient whose nursing diagnosis is "risk for impaired skin integrity." Which of the following lab values places the patient at greatest risk?

Albumen: 1.5 g/dL

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

Debridement

A nurse is caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment?

Dizziness

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

Functional Independence Measure (FIMTM)

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

2.5g/mL

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length?

54 inches

The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?

Bran cereal

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

Lubricating the skin with a non-irritating lotion

A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?

Swing-through

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?

After breakfast

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?

Prone

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

Turning the client every 2 hours and providing a low-air-loss mattress

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

Cooking

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

Priority setting is helpful in dealing with the impact of the disability.

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

Stage III

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

Stage IV

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is

isometric

Rotation of the forearm so that the palm of the hand is down is termed

pronation

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient?

protein

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

reflex (neurogenic) incontinence

Which stage of pressure ulcer is considered a partial-thickness wound?

stage II

The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following time frames?

1 hour

A nurse is performing passive range of motion to a client's upper extremeities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

Opposition

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

Stress incontinence

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)

• Have an adequate intake of fiber containing foods. • Set a daily defecation time that is within 15 minutes of the same time every day. • Have a fluid intake between 2 and 4 L/day.

The nurse assessing a patient on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain on which of the following movements?

Abduction

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 both crutches

The nurse is performing passive range of motion exercises with a patient on a rehabilitation unit. The nurse takes the patient's right hand and touches the thumb to each finger. Later, the nurse documents this range of motion activity as being which of the following?

Opposition

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

Stress incontinence