Ch 10 Prep u

A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. What statement made by the family indicates that more teaching is needed? "We elevate the head of the bed to comfort level throughout the day." "We need to avoid massaging any reddened areas that may appear." "We need to use a mild soap on the skin when bathing." "We need to make sure that the patient drinks enough fluids."

"We elevate the head of the bed to comfort level throughout the day." The elevation of the head of the bed increases the shearing force, so the semi-reclining position should be avoided.

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? PULSES profile Barthel Index Patient Evaluation Conference System Functional Independence Measure

Functional Independence Measure

The nurse and nursing assistant are moving a client who slid down in the chair. What does the nurse encourage the assistant to avoid shearing when moving the client to a higher position in the chair? Lift the client, do not slide them. Encourage the client to slide up without assistance. Tilt the chair back when moving the client. Use a donut device while the client is in the chair.

Lift the client, do not slide them. Avoid shearing, a physical force that separates layers of tissue in opposite directions, such as when a seated client slides downward. Lifting the client and not sliding them will avoid the shearing forces that can tear the skin donut device may cause shearing - do not use

The nurse is caring for a client with a spinal cord injury who has no awareness of the need to void. The nurse should document that the client has which type of incontinence? Stress incontinence Toilet incontinence Reflex (neurogenic) incontinence Functional incontinence

Reflex (neurogenic) incontinence

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage? Stage I Stage IV Stage II Stage III

Stage II

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

Stage IV

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment? Cognitive ability Substance abuse Orientation level Self-care ability

Substance abuse

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? 3-point Swing-to Swing-through 4-point

Swing-through

To help prevent the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use a footboard. a hip-abductor pillow. pillows under the lower legs. 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.

Which term means to move away from the midline of the body? Abduction Extension Adduction Flexion

abduction

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? Grooming Dressing Cooking Bathing

cooking

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

debridement

Which therapeutic exercise is done by the nurse without assistance from the client? Active Isometric Passive Resistive

passive

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 Physical therapist Nurse Physician

patient

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply. potential areas of pressure ulcer development family history of pressure ulcers indwelling catheter output presence of pressure ulcers on the client overall risk of developing pressure ulcers

presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development

The nurse is evaluating the serum albumin of a client newly admitted on the rehabilitation unit. The nurse determines that the client's serum albumin concentration is low, indicating that the client has which deficiency? Phosphorous Calcium Protein Potassium

protein

A client with spinal cord injury has no awareness of the need to void. This type of incontinence is termed toilet incontinence. functional incontinence. stress incontinence. reflex (neurogenic) incontinence.

reflex (neurogenic) incontinence.

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? Prothrombin time Sedimentation rate Serum glucose Serum albumin

serum albumin Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g per dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.

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

stress incontinence

To prevent foot drop, the client is positioned: - in a sitting position with legs hanging off the side of the bed. - to keep the feet at right angles to the leg. - in a side-lying position. - in a semi-sitting position in bed.

to keep the feet at right angles to the leg. When the patient is supine in bed, padded splints or protective boots are used. Semi-Fowler's positioning is used to decrease the pressure of abdominal contents on the diaphragm. In order to prevent foot drop, the feet must be supported. Side-lying positions do not provide support to prevent foot drop.

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? Pillow between the legs Range-of-motion exercises Protective boots Trochanter roll

trochanter roll

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

Air-fluidized surface

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk? Albumin, 1.5 g/dL Hematocrit, 43.5 Hemoglobin, 10.5 Potassium, 3.0

Albumin, 1.5 g/dL

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 Putting slippers on the client's feet Crossing the client's ankles every 2 hours Placing hand rolls on the balls of each foot

Attaching braces or splints to each foot and leg Attaching braces or splints to each foot and leg prevents foot drop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent foot drop 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.

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 pets are present in the home Whether the client needs to navigate stairs routinely at home Whether the client parks his car on the street Whether the client drives a car with a stick shift

Whether the client needs to navigate stairs routinely at home

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

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.