Chapter 10: Principles and Practices of Rehabilitation

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

Stage III Clinically, in a stage III pressure ulcer, a deep crater with or without undermining of adjacent tissues is noted. A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. A stage II ulcer exhibits a break in the skin through the epidermis or dermis. A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the client complains of discomfort

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, how should the nurse explain that the reason for holding a cane on the uninvolved side?

Distributes weight away from the involved side Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Using a cane won't maintain stride length or prevent edema

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 Explanation: Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is

isometric. Explanation: Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Active-assistive exercises are carried out by the patient with the assistance of the therapist or the nurse.

The nurse is performing range-of-motion exercises. Which of the following best depicts dorsiflexion of the foot?

Dorsiflexion where the toes are brought closer to the shin. This decreases the angle between the dorsum of the foot and the leg. For example, when walking on the heels the ankle is described as being in dorsiflexion

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

a trochanter roll extending from the crest of the ilium to the midthigh. Explanation: A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Pillows under the legs will not prevent the hips from rotating externally. A hip-abductor pillow is used for the patient after total hip replacement surgery. A footboard will not prevent the hips from rotating externally

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 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 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." Keeping the patient well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a patient maintain healthy skin, strong or harsh detergents and soaps such as antibacterial soap should be avoided. Mild soap should be used for bathing. Tape or bandages should not be removed quickly, because this action can strip or scrape the skin. Massaging any reddened areas is to be avoided, because this may increase the damage to already traumatized skin and tissue

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." Habilitation focuses on abilities, not disabilities. It begins with the initial contact with the patient. The goal is to restore the patient's ability to function independently or at a pre-illness or pre-injury level of functioning as quickly as possible. If this is not possible, the aims are to maximize independence and prevent secondary disability as well as to promote a quality of life acceptable to the patient. It includes the use of adaptive and assitive devices to promote the greatest level of independence possible

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?

Albumen: 1.5 g/dL Explanation: Patients with albumen levels of less than 3 g/dL are associated with hypoalbuminemic tissue edema and increased risk of impaired skin integrity related to pressure ulcers. Anemia can also increase the risk for pressure ulcers; however, a hemoglobin of 10.5 and a hematocrit of 43.5 are within the normal range. Although potassium of 3.0 is low, this does not put the patient at increased risk for impaired skin integrity

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 Explanation: Instrumental activities of daily living (IADLs) include cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, and handling emergencies. Bathing, grooming, and dressing are activities of daily living (ADLs).

Which nursing intervention can help a client maintain healthy skin?

Keeping the client well hydrated Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.

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 Explanation: Opposition involves touching the thumb to each fingertip on the same hand. Adduction would involve moving the arm away from the midline of the body. Pronation involves rotating the forearm so that the palm of the hand is down. Dorsiflexion involves movement that flexes or bends the hand back toward the body.

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 For clients with disabilities, the nurse would emphasize the use of coping strategies and teach the patient how to cope with the disability through priority setting. A loss of sexual functioning does not necessarily correspond to a loss of sexual feeling. Rather, the physical and emotional aspects of sexuality, despite the physical loss of function, continue to be important for people with disabilities. The fatigue associated with disabilities results from numerous factors, such as the physical and emotional demands, as well as the ineffective coping, unresolved grief, disordered sleep patterns, and depression. Although the most obvious care tasks after discharge involve physical care, other elements of the caregiving role include psychosocial support and a commitment to this supportive role

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 II Explanation: A stage II pressure ulcer is considered a partial-thickness wound. A stage I pressure ulcer is an area of erythema that does not blanch with pressure. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends to the underlying muscle and bone

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

To keep the feet at right angles to the leg When the client 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. To prevent footdrop, the feet must be supported at right angles to the leg. Side-lying positions do not provide support to prevent footdrop

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 shouldn't use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface

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 For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleous would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

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

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. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased. Toilet incontinence occurs in clients who cannot control excreta because of physiologic or psychological impairment. Functional incontinence occurs in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and can not reach and use the toilet before soiling themselves

Students are reviewing information about rehabilitation and brain and spinal cord injuries. They demonstrate understanding of the information when they identify which of the following as being responsible for approximately one-half of all traumatic brain injuries?

substance abuse Half of spinal cord injuries are related to substance abuse, and approximately half of all patients with traumatic brain injury were intoxicated at the time. Motorcycle accidents, genetic predisposition, and work-related injuries do not account for 50% of traumatic brain injuries

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 Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent footdrop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased?

Stress incontinence Stress incontinence may occur with coughing or sneezing, which increase intra-abdominal pressure. Urge incontinence is involuntary elimination of urine associated with a strong perceived need to void. Neurogenic incontinence is associated with a spinal cord lesion. Functional incontinence refers to incontinence in clients with intact urinary physiology and who experience mobility impairment, environmental barriers, or cognitive problems

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

Nutrition support and orthotics Nutrition support should be consulted to evaluate the client's caloric needs for wound healing. Orthotics should also be consulted for specialized footwear designed to keep pressure off the client's heel. Physical therapy is necessary to help the client achieve the highest level of functioning; however, a respiratory consult isn't necessary unless the client has a coexisting respiratory problem. Occupational therapy may be helpful to assist with activities of daily living, but an infectious disease consult isn't necessary unless the client has a coexisting infection. A plastic surgery consult may be necessary if debridement or grafting is likely, but nothing indicates that a cardiology consult is needed

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 Explanation: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased. Toilet incontinence occurs in patients who cannot control excreta because of physiologic or psychological impairment. Functional incontinence occurs in patient with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves.

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.)

Set a daily defecation time that is within 15 minutes of the same time every day Have an adequate intake of fiber containing foods Have a fluid intake between 2 and 4 L/day Regularity, timing, nutrition (including increased fiber intake), and fluids (2 to 4 L daily), exercise, and correct positioning promote predictable defecation (National Institute for Health and Clinical Excellence, 2010). A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily. Enemas and laxatives are only needed if the patient is constipated and then only as needed, not daily

To prevent footdrop, the client is positioned

to keep the feet at right angles to the leg When the 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. Side-lying positions do not provide support to prevent footdrop

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

Stress incontinence Stress incontinence occurs when perineal msucles weaken. Urine subsequently leaks when the intra-abdominal pressure increases, such as with sneezing or coughing. Urge incontinence refers to the involuntary elimination of urine associated with a strong perceived need to void. Functional incontinence occurs in patients with intact urinary physiology but who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex or neurogenic incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void

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 Explanation: A trochanter roll extending from the crest of the ilium to the mid-thigh prevents external rotation of the hip. Range-of-motion exercises are used to maintain muscle strength and joint mobility. Protective boots are used to prevent footdrop. Using a pillow between the legs would help support the body in the correct alignment

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. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

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 stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. A stage III ulcer extends into the subcutaneous tissue. A stage II ulcer exhibits a break in the skin through the epidermis or dermis. A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the client complains of discomfort