PREPU

The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?

Functional incontinence Explanation: The nurse should document this as functional incontinence defined as incontinence when the urinary system is intact and the patient experiences mobility impairment, environmental barriers, or cognitive problems and cannot reach and/or use the toilet before soiling themselves.

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?

Have the patient lie back down. Explanation: The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in 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?

Holds onto the furniture when walking in the house Explanation: Holding onto the furniture or other objects in the room when ambulating suggests difficulty with movement. Using both hands on a handrail while going down stairs, lifting one leg by using the other leg as support, or tilting the head to reach the back of the side while combing would suggest problems with function and mobility.

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

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.

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

Functional Independence Measure (FIMTM) Explanation: One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (FIMTM), a minimum data set consisting of 18 items. The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.

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 Explanation: Indicators of orthostatic hypotension include a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.

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?

Resistive exercises Explanation: Resistive exercises provide resistance to increase muscle power. Passive exercises are used to retain as much joint range of motion as possible and to maintain circulation. Isometric exercises are used to maintain strength when a joint is immobilized. Active exercisess are used to increase muscle strength

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 Explanation: Although the nurse, physician, and physical therapist play important roles in the rehabilitation process, the patient is a key member of the rehabilitation team, the focus of the team's efforts, and the one who determines the final outcomes of the process.

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?

Stage II pressure ulcer Explanation: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

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.

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

Stage IV Explanation: 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 patient complains of discomfort

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?

Step down with the unaffected leg. Explanation: When using a cane to do down stairs, first the patient would step down with the unaffected leg, then place the cane, and then place the affected extremity on the down step.

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

"All weight should be on the hands." Explanation: When using crutches, all weight should be on the hands. Constant pressure on the axillae from weight bearing can damage the brachial plexus nerve and produce crutch paralysis. Feet should be 6? to 8? (15 to 20 cm) apart to provide stability and support. Short strides — not long ones — provide safety and maximum mobilit

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." Explanation: 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.

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

Stage III Explanation: Clinically, 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 patient complains of discomfort.

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

Stress incontinence Explanation: Stress incontinence may occur with coughing or sneezing. 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 patients with intact urinary physiology and who experience mobility impairment, environmental barriers, or cognitive problems.

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

Vitamin C Explanation: Vitamins A and C and the B vitamins are important for healthy skin and wound healing. Vitamins D and calcium are important for bone healing. Adequate protein intake is necessary for improving skin integrity. Vitamin E isn't necessary for wound healing

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

pronation. Explanation: Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that runs 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 client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

turn him frequently. Explanation: The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position

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 Explanation: Risk factors for pressure ulcer development include prolonged pressure on the tissue, sensory deficit or loss, edema, urinary or fecal incontinence, malnutrition, anemia, hypoproteinemia, and excessively moist skin

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

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 can not reach and use the toilet before soiling themselv

Half of all spinal cord injuries are related to which of the following?

Substance abuse Explanation: Of spinal cord injuries, 50% are related to substance abuse, and approximately 50% 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 spinal cord injuries.

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." Explanation: To promote bowel elimination, the nurse should suggest a daily fluid intake of 2 to 3 liters per day unless contraindicated and encourage the patient to respond to the urge to defecate. Increasing the intake of fruits and vegetables and encouraging an increase in physical activity are appropriate to stimulate peristalsis.

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues?

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. Habit training is used to try to keep the patient dry by strictly adhering to a toileting schedule and may be successful with stress, urge, or functional incontinence. Habit training is a type of bladder training.

The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene?

Client moves the arm and leg on the same side together at the same time. Explanation: When using a cane, the client should move the opposite arm and leg together, advance the cane at the same time that the affected leg is moved forward, keep the cane fairly close to the body to prevent leaning, and bear down on the cane when the unaffected extremity begins the swing phase.

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 of the following is an indicator of orthostatic hypotension? a) Dry skin b) Bradycardia c) Dizziness d) Hypertension

Dizziness Explanation: Indicators of orthostatic hypotension include a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.

The nurse working on a rehabilitation unit rotates a patient's forearm so that the palm of the hand is facing down. The nurse documents this movement as which of the following?

Pronation Explanation: Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that runs 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.

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

Braden scale Explanation: The Braden scale may be used to facilitate systematic assessment and quantification of a patient's risk for pressure ulcer, although the nurse should recognize that the reliability of these scales is not well established for all patient populations. PULSES profile is used to assess physical condition, upper extremity functions, and lower extremity functions. The Barthel index is used to measure the patient's level of independence in ADLs. The Functional Independence Measure (FIM) is a minimum data set, measuring 18 items. The FIM addresses transfers and the ability to ambulate and climb stairs and also includes communication and social cognition items.

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 Explanation: To prevent constipation, the patient should eat a diet with an adequate intake of high-fiber foods; therefore, the nurse should encourage the patient to select the bran cereal.

A patient who has experienced a stroke is learning to use a cane to ambulate. The patient has left-sided weakness. After teaching the patient about using the cane, the nurse determines that the patient has understood the instructions when stating that using the cane on the right is done for which purpose?

To distribute weight away from the affected side Explanation: 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 promote a long stride length or reduce the risk of edema

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 Explanation: Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

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

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.

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?

Ulnar deviation Explanation: Moving the hand sideways so that the side of the hand with the little finger moves toward the forearm reflects ulnar deviation. Supination occurs when the elbow is at the waist, the arm is bent at a 90-degree angle, and the hand is turned so that the palm is facing up. Thumb opposition occurs when the thumb moves out and around to touch the little finger. Wrist flexion occurs when the wrist is bent so that the palm is toward the foreaem

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?

Whether the client needs to navigate stairs routinely at home Explanation: Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches.

In order 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

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. Explanation: 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.

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:

document the condition of the client's skin. Explanation: The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy

A type of therapeutic exercise performed by the patient where the muscle 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.

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest?

Emphasize areas of strengths. Explanation: To assist a patient in coping with his or her disability, the nurse would encourage the patient to emphasize strengths, stop activities before fatigue occurs, distribute heavy work throughout the day or week, and recruit assistance from others, delegating when necessary.

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." Explanation: 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 assistive devices to promote the greatest level of independence possible.

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 Explanation: 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.

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." Explanation: When using crutches, body weight is supported by the arms and hands. The top of the crutches should be approximately 2 inches below the axillae. The axillae should not support the weight of the body. Crutches should be positioned on either side of each foot, just slightly ahead of each foot. Patients should be taught two gaits so that they can change from one type to another to avoid fatigue. Additionally, a faster gait can be used when walking an uninterrupted distance, and a slower gait can be used for short distances or in crowded places

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." Explanation: For effective tissue healing, adequate intake of protein, and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to provide these nutrients. The bandage should be secure but not tight enough to impede circulation to the area (which is needed for tissue repair). If the client's foot feels cold, circulation is impaired, thus inhibiting wound healing.

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?

1 hour Explanation: The initial sign of pressure is erythema caused by reactive hyperemia that normally resolves in less than 1 hour. All of the other timeframes are incorrect.

The initial sign of skin pressure is erythema, which normally resolves in less than

1 hour. Explanation: The initial sign of pressure is erythema caused by reactive hyperemia that normally resolves in less than 1 hour. All of the other timeframes are incorrect

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?

2.5 g/mL Explanation: Serum albumin is a sensitive indicator of protein deficiency. Levels below 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulce

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

25 degree flexion Explanation: When a walker is at the right height for a patient, the patient's elbows are between 20 and 30 degrees flexion when the hands are resting on the hand grip.

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 Explanation: When using a patient's height to determine the appropriate crutch length, the nurse subtracts 16 inches (40 cm) from the patient's height. In this situation, the patient's height of 70 inches minus 16 inches equals a crutch length of 54 inches.

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 wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance Explanation: A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place. Although option A describes a large wound, it's showing signs of healing, so a consult isn't necessary. Option B describes a stage II wound that has a clean wound bed; a wound nurse consult isn't necessary for this type of wound. The wound described in option D is small and shows signs of healing; a wound care consult isn't required at this time.

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 Explanation: Abduction is the movement away from the midline of the body. Adduction is the movement toward the midline of the body. Flexion is the bending of a joint so that the angle of the joint diminishes. Extension is the return movement from flexion

Which of the following terms means movement away from the midline of the body?

Abduction Explanation: Abduction is the movement away from the midline of the body. Adduction is the movement toward the midline of the body. Flexion is the bending of a joint so that the angle of the joint diminishes. Extension is the return movement from flexion.

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document? ly.

Abduction Explanation: Movement away from the body or midline is called abduction. Movement toward the midline is called adduction. Pronation is the act of turning the hand so the palm faces downward. Supination is the act of turning the palm anterior

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?

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. However, the client maintained on this surface should be monitored closely because this bed places the client at risk for dehydration. The static support surface is designed to prevent stage II pressure ulcers; it isn't designed to care for the client with multiple stage III wounds. Although the alternating air surface is effective for a client with multiple wounds, it doesn't offer enough pressure reduction for complex wounds occurring on multiple surfaces. The low-air-loss surface protects the skin from moisture, but it doesn't offer enough pressure reduction for this client.

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 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 caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; doing so can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs

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

Attaching braces or splints to each foot and leg Explanation: 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 alignm

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 Explanation: 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.

Students are reviewing information about activities of daily living. They demonstrate understanding of this topic when they identify which of the following as an activity of daily living?

Bathing Explanation: Activities of daily living refer to those activities involving personal care such as bathing, showering, dressing, getting in and out of bed or a chair, using the toilet, and eating. Cleaning, doing laundry, and handling emergencies are examples of independent activities of daily living.

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding. Explanation: Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage? .

Cranberry juice Explanation: Patients at risk for infection secondary to urine retention should be encouraged to drink acid-producing fluids such as cranberry or cranapple juice. Milk shakes, tomato juice, and carbonated colas are alkaline-producing fluids that promote bacterial growth in the urine

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) Irrigation c) Incision and drainage d) Debridement

Debridement Explanation: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule. Explanation: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing

A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?

Diminished dermal collagen Explanation: Slowed peristaltic activity would be a contributing factor for an older adult's risk for developing constipation. Older adults are more susceptible to pressure ulcers because of diminished epidermal thickness, dermal collagen, and tissue elasticity. The skin is drier due to a decrease in sebaceous and sweat gland activity. Sensory perception also is diminished.

The nurse preceptor is critiquing a new nurse's plan of care for a patient with urinary incontinence. The preceptor suggests a review of nursing interventions for urinary incontinence when which of the following appear on the plan of care?

Encourage cranberry juice Explanation: Appropriate nursing interventions for patients with urinary incontinence include encouraging acid based fluids such as cranberry juice, initiation of a toileting schedule, and encouragement of Kegel exercises. The patient's fluids should not be restricted to ensure adequate fluid intake. The preceptor attributes the error on the new nurse's care plan to a lack of knowledge and suggests that the new nurse review nursing interventions for urinary incontinence

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 Explanation: When intermittent self-catheterization is used, the nurse would emphasize regular emptying of the bladder rather than sterility. The catheter is inserted for the length of time it would take to empty the bladder. A regular schedule, not evidence of bladder distention, is used to guide the frequency of the procedure

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 Explanation: Incontinence and right-sided hemiparesis place the client at risk for skin breakdown. Visual deficits, dysarthria, constipation, and lower extremity weakness don't place the client at risk for skin breakdown.

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 Explanation: 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.

The nurse is creating a bowel evacuation program for a paraplegic patient. When should the nurse plan for administration of a suppository?

Just before breakfast Explanation: The best time to plan for bowel evacuation when establishing a bowel regime is 30 minutes after breakfast to take advantage of natural reflexes. Suppositories to promote evacuation should be administered 30 minutes prior to the desired evacuation time. Therefore, the nurse in this example should plan for the suppository to be administered just before the patient's breakfast

Which nursing intervention can help a client maintain healthy skin?

Keeping the client well hydrated Explanation: 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.

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

Keeping the skin clean and dry without using harsh soaps Explanation: Keeping the skin clean and dry is always the highest priority. Changing the client's position frequently and gently massaging the skin around the pressure areas are also important but only after the skin is cleaned. The nurse should rub lotion around, not directly over, pressure areas to avoid skin breakdown.

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

Lubricating the skin with a non-irritating lotion Explanation: To help reduce the risk of pressure ulcers, the nurse should lubricate the skin with a bland lotion to keep it soft and pliable. Reddened areas should not be massaged because this could damage the capillaries and deep tissues. Clients should shift their weight every 15 to 20 minutes. The semi-reclining position should be avoided because it increases the shearing forces over the sacral area.

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture Explanation: Although skin color, tissue perfusion, and drainage are important assessment areas to address, the Braden scale uses the following categories to predict pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?

Moving the walker, stepping with the affected leg, then stepping with the unaffected leg Explanation: The walker is designed to take the weight from the affected leg. Therefore, the nurse should instruct the client to move the walker, step with the affected leg, and then step with the unaffected leg.

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

Nutrition support and orthotics Explanation: 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.

While performing range-of-motion exercises for a patient, the nurse abducts the patient's shoulder. Which of the following images best depicts the nurse's action?

PICTURE ANSWER! Explanation: During abduction of the shoulder, the nurse moves the arm from the side of the body to above the head and then returns the arm to the side of the body (neutral position). With forward flexion of the shoulder (option B), the nurse moves the arm forward and upward until it is alongside the head. For flexion of the elbow (option C), the nurse bends the elbow, bringing the forearm and hand toward the shoulder, and then returns the forearm and hand to the neutral position. When internally rotating the shoulder (option D), the arm is at shoulder height, the elbow is bent at a 90-degree angle, and the palm is toward the feet. The nurse turns the upper arm until the palm and forearm point backward.

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

PICTURE ANSWER! Explanation: With dorsiflexion (Option B), the nurse moves the foot up and down toward the leg. Flexion of the hip and knee (Option A) involves bending the hip by moving the leg forward as afar as possible and then returning it to the neutral position. Inversion and eversion (Option C) involves moving the foot so that the sole is facing outward (eversion) and then so that the sole is facing inward (inversion). Flexion of toes (Option D) involves bending the toes toward the ball of the foot.

After teaching a patient about the proper method for using crutches to assist in ambulation, the nurse observes the patient's crutch-gait. The nurse determines that the patient has understood the instructions when the patient demonstrates which of the following images as the beginning stance? Note that the shaded areas are weight-bearing and the arrows indicate advancement of the footh or crutch.

PICTURE ANSWER!!! Explanation: When initiating a crutch gait, the patient places the crutches evenly apart just above and laterally to the feet. Both feet are on the ground. Advancing the left foot and right crutch (as in option B) is the second step when using the 2-point gait. Lifting both feet, swinging forward, and landing feet next to the crutches (as in option C) is the second step when using the swing-to gait. Advancing the left crutch (as in option D) is the next-to-last step when using the 4-point gait.

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

Passive Explanation: Passive therapeutic exercise is carried out by the therapist or the nurse without assistance from the patient. Active therapeutic exercises are accomplished by the patient without assistance. Resistive exercise is carried out by the patient working against resistance produced by either manual or mechanical means. Isometric exercise is described as alternately contracting and relaxing a muscle while keeping the part in a fixed position.

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. Explanation: 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.

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 Explanation: When hyperextending the hip, the patient is placed in the prone position and the leg is moved backward from the body as far as possible. The supine position is used for all other range-of-motion exercises.

Serum albumin is an indicator of which type of deficiency?

Protein Explanation: Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

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 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?

Pushes the popliteal area against the mattress while raising the heel Explanation: The client demonstrates quadriceps-setting exercises by attempting to push the popliteal area against the mattress and at the same time raising the heel. With gluteal setting exercises, the client contracts the buttocks together for a count of five and then relaxes them for a count of five. With push-up exercises, the client raises the body by pushing the hands against the chair seat or mattress while he is in a sitting position. For pull-up exercises, the client lifts the body off the mattress while holding onto a trapeze while in bed or raises the arms above the head then lowers them while holding weights.

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?

Recumbent Explanation: Although a patient should be repositioned laterally, prone, and dorsally in sequence, the recumbent position is preferred to the semi-Fowler's position because this position provides an increased body surface area of support.

The nurse is caring for a patient with a spinal cord injury who has no awareness of the need to void. The nurse should document that the patient has which of the following types 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.

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?

Repositioning the patient about once a shift Explanation: Turning should occur every 1 to 2 hours — not once a shift — for patients who are in bed for prolonged periods. The nurse should apply a non-irritating lotion, use static support devices to relieve pressure, and lift rather than slide the patient when repositioning to reduce shearing forces.

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?

Resistive Explanation: The nurse should incorporate exercise, which involves the use of light weights as resistive exercises. In active-assistive exercises the patient performs the exercises with assistance from the therapist. In passive exercises, the nurse performs the exercise for the patient without assistance from the patient. In isometric exercises, the patient alternately contracts and relaxes the muscle while keeping the part in a fixed position.

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 Explanation: 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 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?

Specialty boots Explanation: The area of skin breakdown was most likely caused by the specialty boot — ordered to reduce pressure in the heels — rubbing against the skin. Although the wheelchair leg rest is located near the wound site, the wound described is likely to be caused by pressure, not a laceration caused by contact with the leg rest. Immobility and decreased sensation places the client at risk for skin breakdown, but these factors aren't the direct cause of this wound. A paraplegic is capable of sitting in a wheelchair for extended periods because he can shift his weight throughout the day.

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 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.

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?

Stage III Explanation: A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. A stage I ulcer is characterized by an area of erythema that does not blanch with pressure. A stage II ulcer is a partial-thickness wound characterized by a break in the skin with edema and some drainage. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

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

Stress incontinence Explanation: Stress incontinence occurs when perineal muscles 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.

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 Explanation: The patient is demonstrating the swing-through gait, in which both crutches are advanced and then both feet are swung forward, landing in front of the crutches. The 4-point gait involves advancing the right crutch, then the left foot, then the left crutch, and then the right foot. The 3-point gait involves advancing the left foot and both crutches, then advancing the right foot, then advancing the left foot and both crutches, and finally advancing the right foot. The swing-to gait involves advancing both crutches and then lifting both feet, swinging them forward and landing them next to the crutches

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 Explanation: 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.

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 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 Explanation: To avoid pressure ulcers in an immobilized client, the nurse must assess the skin thoroughly and use such preventive measures as regular turning, a low-air-loss mattress, and a trapeze (if the client's condition allows). The nurse should increase, not decrease, the client's fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having the client cough, deep breathe, and use an incentive spirometer would be more effective than raising the head of the bed. Instead of bathing and feeding the client, the nurse should promote independent self-care activities whenever possible to prepare the client for a return to the previous health status.

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. 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. 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.

To prevent footdrop, the patient is positioned

to keep the feet at right angles to the leg. Explanation: 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

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 Explanation: ADLs refer to those activities related to personal care, such as bathing, using the toilet, and eating. Cleaning and cooking are independent ADLs--activities that are important for independent living.

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

• Stage III • Stage IV Explanation: Stages III and IV pressure ulcers are considered full-thickness wounds. Deep tissue injury is a localized area of discolored, purple, intact skin or blood-filled blister caused by underlying soft tissue damage from pressure or shear. Stage I ulcer is characterized by erythema. Stage II pressure ulcer is a partial-thickness wound