Med Surg Chapter 10 Quiz

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

- Set 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 per day.

Serum albumin levels less than -------- increase the risk of pressure ulcers. Therefore, a protein intake of ------------- is recommended to promote ulcer healing.

3 g/dL; 1.25-1.5 g/Kg

What diet can't eh nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

Movement away front eh midline of the body

Abduction

Movement toward the midline of the body

Adduction

Alkaline producing beverages such as-------------- promote bacterial growth in the urine and should be avoided for patients who suffer from incontinence.

Carbonated soft drinks, milk shakes, alcoholic drinks and citrus drinks

Beding of the foot toward the leg

Dorsiflexion

The initial sign of pressure is ----------------, which is caused by ---------------- -----------, unrelieved pressure results in ------------------ and -------------.

Erythema, Reactive Hyperemia, Tissue ischemia and anoxia

Increasing the angle of a joint

Extension

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

Hyperemia

Movement that turns the sole of the foot inward

Inversion

A life threatening complication of a state IV pressure ulcer is:

Osteomyelitis

The nurse is as siting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction.

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures

Rotating the forearm so that the palm is down

Pronation

Two areas that are the most susceptible to the effects of shear and therefore pressure ulcer formation are the ------------ and the --------.

Sacrum; heels

What position should be avoided when positioning a patient in bed in order to decrease the incidence of musculoskeletal complications?

Semi Fowlers

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

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor int eh patient with a disability attempting to seek employment?

Substance abuse

The nurse has developed an evidence based pan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

The patient

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?

With initial patient contact

Name three complications commonly associated with prolonged or impaired physical immobility:

1. Weakened muscles 2. Joint contractures 3. Deformities

Four factors that contribute to foot drop are:

1. Prolonged bed rest 2. Lack of exercise 3. Incorrect positioning in the bed 4. Weight of the bedding

Four microorganisms that contribute to infection in pressure ulcers are:

1. Streptococci, Staphylococci, Pseudomonoas aeruginosa, and escherichia coli

List eight specialty rehabilitation programs accredited by the Commission for the Accreditation of Rehabilitation Facilities:

1. Stroke recovery and traumatic brain injury 2. Spinal cord injury 3. Orthopedic 4. Cardiac 5. Pulmonary 6. Pediatric 7. Comprehensive pain management 8. Rehabilitation are specialty rehabilitation programs accredited by CARF

Name the three goals of rehabilitation.

1. To restore the patients ability to function independently or at a pre-illness or pre-injury level. 2. Maximize independence 3. Prevent secondary disability.

Four major rehabilitative goals are:

1. Absence of contracture and deformity 2. Maintenance of muscle strength and joint mobility 3. Independent mobility 4. Increased activity tolerance 5. Prevention of Further disability

Two common musculoskeletal complications for patients who are in bed for prolonged periods are:

1. External rotation of the hip 2. Plantar flexion of the foot

Five nursing diagnoses for patients with impaired physical mobility could be:

1. Impaired physical mobility 2. Activity intolerance 3. Risk for injury 4. Risk for douse syndrome 5. Impaired Walking 6. Impaired Wheelchair mobility 7. Impaired bed Mobility

The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use?

Barthel Index

Two assessment scales that nurses can use to quantify a patient's risk for pressure ulcer formation are the:

Braden scale and the norton scales.

Eschar covering an ulcer should be removed surgically for what reason?

Eschar does not permit free drainage of the tissue

To maintain use, a joint should be moved through its range of motion at least --------- times a day.

Three

The nurse is initiating a bladder training schedule for patient. What interventions can be provided for optimal success? (Select all that Apply)

- Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. - Give up to 3,000 mL of fluid daily - Teach bladder massage to increase intra-abdominal pressure.

A patient in rehabilitation has become dependent on family members assistance with self care. What can't he nurse do to encourage the patient to become independent? (Select all that apply)

- Motivate the patient to learn and accept responsibilities for self care. - Help the patient identify safe limits of independent activity. - Educate the patient in how to perform self care activities.

List four collaborative problems for a patient with impaired physical mobility:

1. Impaired physical mobility 2. Activity intolerance 3. Risk for Injury 4. Risk for disuse syndrome

The nurse is fitting a patient for crutches that are required for an snake injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height?

Use the patients height and subtract 16 inches.