Medsurg II Chapter 10 - Principle and Practices of Rehab

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply. a) Sensory overload b) Anemia c) Edema d) Diaphoresis e) Constipation

• Edema • Anemia • Diaphoresis

Which nursing intervention can help a client maintain healthy skin? a) Avoiding bathing the client with mild soap b) Removing adhesive tape quickly from the skin c) Keeping the client well hydrated d) Recommending wearing tight-fitting clothes in hot weather

Keeping the client well hydrated

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? a) Specialty mattress b) Water bed c) Gel flotation pad d) Ring or donut

Ring or donut

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures? a) Performing shoulder range-of-motion (ROM) exercises b) Applying knee splints c) Elevating the foot of the bed d) Hyperextending the client's legs

Applying knee splints

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein? a) A diet high in fats b) A diet high in minerals c) A diet high in carbohydrates d) A diet high in vitamins

A diet high in carbohydrates

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? a) Barthel Index b) The Braden Scale c) Patient evaluation conference system d) The Pulses Profile

Barthel Index

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues? a) Biofeedback b) Habit training c) Bladder training d) Kegel exercises

Biofeedback Explanation: Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback Kegel exercises are pelvic floor exercises that strengthen the pubococcygeus muscle.

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage I b) Stage IV c) Stage III d) Stage II

Stage III

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following? a) Reflex incontinence b) Stress incontinence c) Functional incontinence d) Urge incontinence

Stress incontinence

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed a) stress incontinence. b) reflex (neurogenic) incontinence. c) functional incontinence. d) toilet 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.

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? a) Hematocrit: 43.5 b) Albumen: 1.5 g/dL c) Potassium: 3.0 d) Hemoglobin: 10.5

Albumen: 1.5 g/dL

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? a) Bananas b) Applesauce c) Bran cereal d) Pop tart

Bran cereal

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

Stage IV

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility? a) Raising the head of the bed to maximize the client's lung inflation b) Decreasing fluid intake to ease dependent edema c) Turning the client every 2 hours and providing a low-air-loss mattress d) Bathing and feeding the client to decrease energy expenditure

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

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height? a) Use the patient's height and subtract 8 inches. b) Use the patient's height and subtract 16 inches. c) Use the patient's height and add 12 inches. d) Use the patient's height and add 6 inches.

Use the patient's height and subtract 16 inches.

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. a) Toileting b) Cleaning c) Bathing d) Eating e) Cooking

• Toileting • Bathing • Eating

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? a) "Habilitation begins once the patient is ready for discharge." b) "Habilitation negates the need for assistive devices." c) "Habilitation focuses on the person's abilities." d) "Habilitation is primarily geared to those who can achieve independence."

"Habilitation focuses on the person's abilities."

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) Pillows under the lower legs b) A hip-abductor pillow c) A footboard d) A trochanter roll extending from the crest of the ilium to the midthigh

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

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following? a) Client does not reach the toilet before experiencing voiding. b) Client leaks urine when coughing or sneezing. c) Client lacks the sensory awareness about the need to void. d) Client expereinces a strong perceived urge to void.

Client does not reach the toilet before experiencing voiding.

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next? a) Encourage the patient to take deep breaths. b) Have the patient lie back down. c) Obtain a transfer board to ease the change. d) Have the patient stand up immediately.

Have the patient lie back down.

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? a) Ischial tuberosity b) Scapula c) Lateral malleous d) Greater trochanter

Ischial tuberosity (sitz bone)

The nurse is creating a bowel evacuation program for a paraplegic patient. When should the nurse plan for administration of a suppository? a) Just before breakfast b) 1 hour before dinner c) 30 minutes after lunch d) Right before bed

Just before breakfast

Which nutritional deficiency may delay wound healing? a) Lack of vitamin E b) Lack of calcium c) Lack of vitamin D d) Lack of vitamin C

Lack of vitamin C

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown? a) Place an indwelling catheter in the patient. b) Apply powder. c) Administer vitamin B12 to the patient. d) Practice meticulous hygiene measures.

Practice meticulous hygiene measures.

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? a) Zinc sulfate b) Water c) Vitamin C d) Protein

Protein

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following? a) Raises the body by pushing the hands against the chair seat b) Contracts the buttocks together for a count of five c) Lifting the body off the bed while holding on to a trapeze d) Pushes the popliteal area against the mattress while raising the heel

Pushes the popliteal area against the mattress while raising the heel

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers? a) Lifting rather than sliding the patient when repositioning her b) Lubricating the skin with a non-irritating lotion c) Using a static support device on the patient's bed d) Repositioning the patient about once a shift

Repositioning the patient about once a shift

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first? a) Step down with the unaffected leg. b) Step down with the affected leg. c) Place cane and affected leg on step simultaneously. d) Place the cane on the lower step.

Step down with the unaffected leg.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? a) The patient b) The nurse c) The physical therapist d) The physician

The patient

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: a) advance the unaffected leg. b) advance the affected leg. c) advance both crutches. d) advance both legs.

advance both crutches.

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is a) isometric. b) passive. c) resistive. d) active-assistive.

isometric

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? a) "I need to allow my arms and hands to support my body weight." b) "I need to learn to use one type of gait for getting around." c) "I should make sure my underarms are supported by the tops of the crutches." d) "I need to position the crutches even with my heels when standing."

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

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse? a) A wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue b) A wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed c) A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance d) A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue

A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue

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? a) After breakfast b) Before bed c) Around lunchtime d) Upon arising

After breakfast

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

Hyperemia Explanation: 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.

Which disciplines should be consulted when caring for a client with a stage III heel ulcer? a) Nutrition support and orthotics b) Occupational therapy and infectious disease c) Plastic surgery and cardiology d) Physical therapy and respiratory therapy

Nutrition support and orthotics

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? a) Palmar flexion b) Inversion c) Supination d) Opposition

Opposition

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? a) Stage III pressure ulcer b) Stage I pressure ulcer c) Stage II pressure ulcer d) Stage IV pressure ulcer

Stage II pressure ulcer

To prevent footdrop, what is the best way for the nurse to position the patient? a) To keep the feet at right angles to the leg b) In a semisitting position in bed c) In a sitting position with legs hanging off the side of the bed d) In a side-lying position

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? a) Trochanter roll b) Protective boots c) Range-of-motion exercises d) Pillow between the legs

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

Rotation of the forearm so that the palm of the hand is down is termed a) supination. b) pronation. c) eversion. d) inversion.

pronation

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? a) 3.1 g/mL b) 4.0 g/mL c) 2.5 g/mL d) 3.5 g/mL

2.5 g/mL

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? a) Cooking b) Bathing c) Dressing d) Grooming

Cooking 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)

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? a) Culture b) Incision and drainage c) Debridement d) Irrigation

Debridement

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care? a) Having the client shift his or her weight every hour b) Placing the client in a semi-reclining position c) Lubricating the skin with a non-irritating lotion d) Massaging any reddened areas of the skin

Lubricating the skin with a non-irritating lotion

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter? a) Potential areas of pressure ulcer development b) Overall risk of developing pressure ulcers c) Family history of pressure ulcers d) Presence of pressure ulcers on the client

Overall risk of developing pressure ulcers

Which therapeutic exercise is done by the nurse without assistance from the patient? a) Resistive b) Active c) Passive d) Isometric

Passive

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown? a) Specialty boots b) Sitting in the wheelchair for long periods of time c) Absence of sensation in the lower extremities and immobility d) Leg rest of the wheelchair

Specialty boots

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? a) Swing-to b) 3-point c) 4-point d) Swing-through

Swing-through

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? a) Patient b) Nurse c) Physical therapist d) Physician

Patient

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage? a) Stage IV b) Stage II c) Stage III d) Stage I

Stage III A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. Explanation: A stage I area of erythema that does not blanch with pressure. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury? a) After the patient feels comfortable in the clinical setting b) When an exercise program has been initiated c) With initial patient contact d) After the physician has prescribed rehabilitative goals

With initial patient contact

Which nutritional deficiency may delay wound healing? a) Lack of vitamin C b) Lack of vitamin E c) Lack of calcium d) Lack of vitamin D

Lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing.

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: a) functional incontinence. b) reflex incontinence. c) total incontinence. d) stress incontinence.

stress incontinence Explanation: Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences? a) Alternating pressure surface b) Low-air-loss surface c) Air-fluidized surface d) Static support surface

Air-fluidized surface Explanation: The air-fluidized surface is the best choice for this client because this surface protects the skin from moisture — an important feature for the client who can't change position on her own

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

Attaching braces or splints to each foot and leg

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power? a) Passive exercises b) Active exercises c) Isometric exercises d) Resistive exercises

Resistive exercises

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased? a) Urge incontinence b) Functional incontinence c) Reflex (neurogenic) incontinence d) Stress incontinence

Stress incontinence

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? a) Stage IV b) Stage II c) Stage III d) Stage I

Stage II A stage II ulcer is a partial-thickness wound, break in the skin with edema and some drainage.

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? a) "We need to make sure that the patient drinks enough fluids." b) "We need to massage any reddened areas that may appear." c) "We need to remove any tape or bandages from the skin quickly" d) "We need to use an antibacterial soap on the skin when bathing."

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

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 timeframes? a) 45 minutes b) 1 hour c) 30 minutes d) 15 minutes

1 hour

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? a) Dizziness b) Bradycardia c) Dry skin d) Hypertension

Dizziness

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? a) Extension b) Flexion c) Abduction d) Adduction

Abduction

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? a) Skin color b) Tissue perfusion c) Drainage d) Moisture

Moisture Braden scale uses: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide? a) Extend the legs with a firm support under the popliteal area. b) Position the trunk so that hip flexion is minimized. c) Align the lower extremities in a neutral position. d) Place the uppermost hip slightly forward in a position of slight abduction.

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

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? a) Priority setting is helpful in dealing with the impact of the disability. b) A loss of sexual functioning correlates with a loss of sexual feeling. c) Fatigue primarily results from physical demands. d) Most care tasks required after discharge focus on the physical care.

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

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? a) Phosphorous b) Potassium c) Protein d) Calcium

Protein

The nurse is working with the physical therapist to create a multidisciplinary plan of care for a patient in a rehabilitation unit. The therapist suggests that the patient would benefit from the use of light weights during shoulder exercises. The nurse incorporates this onto the plan of care as which of the following types of exercise? a) Active-assistance b) Isometric c) Resistive d) Passive

Resistive

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? a) Prothrombin time b) Serum albumin c) Sedimentation rate d) Serum glucose

Serum albumin

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client? a) Whether pets are present in the home b) Whether the client parks his car on the street c) Whether the client drives a car with a stick shift d) Whether the client needs to navigate stairs routinely at home

Whether the client needs to navigate stairs routinely at home

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: a) contact the client's family. b) document the condition of the client's skin. c) give the client a donut ring to reduce pressure on the affected area. d) do nothing; the client's skin is intact.

document the condition of the client's skin.

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.) a) Take a retention enema daily. b) Take a laxative daily. c) Set a daily defecation time that is within 15 minutes of the same time every day. d) Have an adequate intake of fiber containing foods. e) Have a fluid intake between 2 and 4 L/day.

• 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.