Ch 39: Rehabilitation Nursing

8. The rehabilitation nurse outlines the need for comprehensive rehabilitation for better functional outcomes for the patient. A comprehensive rehabilitation plan of care must be implemented following admission within: a. 12 hours. b. 24 hours. c. 3 days. d. 1 week.

ANS: B A comprehensive rehabilitation plan is initiated within 24 hours of admission to the rehabilitation service. REF: Page 1211 TOP: Rehabilitation

12. The nurse recognizes that the acquisition of adaptive skills and behaviors by an individual who has been disabled since birth is referred to as: a. training. b. education. c. development. d. habilitation.

ANS: D Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills to relearn and are habilitated rather than rehabilitated. REF: Pages 1212-1213 TOP: Habilitation

33. The rehabilitation nurse references the nursing diagnosis of impaired cognition for a 40-year-old patient who is brain injured and who: a. frequently becomes violent. b. becomes easily fatigued. c. is depressed. d. cannot add three numbers in his head.

ANS: D Impaired cognitive barriers experienced during rehabilitation include problems in thinking, impaired concentration, and impaired information processing. REF: Page 1218 TOP: Rehabilitation

24. When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, the initial intervention is to: a. locate the cause of irritation. b. assess the blood pressure. c. cover the patient with several blankets. d. raise the head of the bed to a high Fowler's position.

ANS: D Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension. REF: Page 1217 TOP: Rehabilitation

2. The nurse recognizes that the rehabilitation process involves the efforts of various disciplines whose focus is to build on a person's: a. losses. b. long-term plans. c. drives. d. abilities.

ANS: D The underlying philosophy of rehabilitation is to focus on abilities. REF: Page 1209 TOP: Rehabilitation

16. The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering an episode of: a. paresis. b. heterotopic ossification. c. postural hypotension. d. autonomic dysreflexia.

ANS: D Autonomic dysreflexia is caused by a reflex action of the autonomic nervous system. REF: Page 1217 TOP: Rehabilitation

39. The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in his practice is said to be .

ANS: culturally competent A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice. REF: Page 1208 TOP: Culture

37. The rehabilitation nurse assesses localized edema around the knee of a patient with paraplegia. The nurse suspects that this is the first sign of .

ANS: heterotopic ossification Heterotopic ossification is a bony growth in joints of spinal cord injury patients that ultimately limits range of motion. REF: Page 1217 TOP: Rehabilitation

38. A child who was struck by a car and suffered a closed head injury was unconscious for 24 hours before waking. The nurse recognizes this as a brain injury.

ANS: moderate A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury. REF: Page 1218 TOP: Rehabilitation

30. The rehabilitation nurse tells the patient that a truly successful quality rehabilitation program will result in a patient who: a. continually strives to gain greater independence. b. becomes employed. c. views himself realistically. d. reenters the community.

ANS: A A rehabilitation program can be considered a success if the patient is stimulated to continue to increase his independence, whether or not he becomes employed or reenters the community. REF: Page 1209 TOP: Rehabilitation

13. The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also the debilitating factor of: a. advancing age. b. reduced ability to learn. c. limited energy. d. eroded interest level.

ANS: A Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. REF: Page 1213 TOP: Rehabilitation

31. The rehabilitation nurse recognizes that the majority of head injuries show no abnormal neurological findings and experience no loss of consciousness, which categorizes them as: a. mild. b. moderate. c. severe. d. catastrophic.

ANS: A Mild brain injury is characterized by no loss of consciousness and no abnormal neurological findings. REF: Page 1218 TOP: Rehabilitation

36. The nurse explains that the Americans with Disabilities Act of 1990 defines a person as disabled if which criteria are met? (Select all that apply.) a. The person has a physical or mental disability. b. The person is limited in a major life activity. c. The person has a medical record of the impairment. d. The person is unemployed. e. The person needs assistance in completion of ADLs.

ANS: A, B, C The definition is that a disabled person may have a physical or mental disability that limits him or her in a major life activity and has a medical record of that disability. DIF: Cognitive Level: Comprehension REF: Pages 1207-1208 OBJ: 4 TOP: Americans with Disabilities Act (ADA)

35. What are the characteristics of chronic illness as compiled by the Commission on Chronic Illness? (Select all that apply.) a. The illness requires specialized training for rehabilitation. b. The illness cannot be overcome. c. The illness is permanent. d. The illness has an unpredictable outcome. e. The illness leaves a residual disability.

ANS: A, C, E The Commission listed among the characteristics of chronic illness that chronic illness requires specialized, specific training for rehabilitation; the effects of the illness are permanent; and the illness leaves a residual disability. REF: Page 1207 TOP: Rehabilitation

22. The nurse recognizes that a handicap differs from impairment in that a handicap is: a. a loss of function. b. a disadvantage that limits a particular individual in his or her usual role performance. c. a specific restriction to perform an activity or role. d. usually of a physical nature.

ANS: B A handicap is a disadvantage for a given individual from an impairment that limits his or her role performance. A particular handicap for one person might not pose any handicap for another with the same disability. REF: Page 1207 TOP: Rehabilitation

7. When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on the goal of: a. returning to normal. b. independence. c. employment. d. promotion of health.

ANS: B A rehabilitation nurse must help the patient focus on increasing independence. REF: Page 1209 TOP: Rehabilitation

20. When caring for a 32-year-old Hispanic male who has become disabled, the rehabilitation team will set the priority of treatment goals based on the: a. difficulty of the language barrier. b. cultural significance of the disability. c. depth of the patient's support system. d. attitude toward rehabilitation.

ANS: B Culture defines the significance of disease and disability. Although all of the options must be addressed, the significance of the disability has highest priority. REF: Page 1208 TOP: Rehabilitation

23. To decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury, the nurse will: a. massage the patient's legs daily. b. perform passive range-of-motion exercises. c. encourage frequent warm baths. d. allow the patient's legs to dangle for a period of 10 minutes several times a day.

ANS: B DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT. REF: Page 1207 TOP: Rehabilitation

21. When pointing out the economic significance of rehabilitation, the rehabilitation nurse uses a chart to show that for every dollar spent on rehabilitation, the amount saved is: a. $2. b. $3. c. $4. d. $5.

ANS: B For every $1 spent on rehabilitation, $3 is saved in public funds that would have been used for residential care of the disabled. REF: Page 1208 TOP: Rehabilitation

17. The nurse instructs the mother of a 5-year-old who sustained a mild brain injury that although all neurological evaluations are normal, her child may exhibit postconcussive syndrome, which is characterized by: a. convulsions and high fever. b. irritability and memory deficits. c. muscular twitching and muscle pain. d. paresis of limbs.

ANS: B Mild brain injury is characterized by brief or no loss of consciousness. This type constitutes the majority of head injuries. Neurological examinations are often normal. Postconcussive syndrome can persist for months, years, or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed, and memory, understanding, learning, and perceptual difficulties. REF: Page 1218 TOP: Rehabilitation

6. Approximately 50% of the rehabilitation nurse's contribution to the rehabilitation effort is having a broad knowledge base of the pathophysiology modalities of rehabilitation. The other major contribution is: a. implementation. b. encouragement. c. evaluation. d. cooperation.

ANS: B Nurses practicing in the area of rehabilitation believe that individuals with functional disabilities have an intrinsic worth that transcends their disabilities. Rehabilitation nursing is an attitude in addition to a set of specialized knowledge and skills. Estimates are that 50% of rehabilitation nursing is know-how; the other 50% is simple open-minded encouragement. REF: Page 1210 TOP: Rehabilitation

28. The nurse teaches a patient that autonomic dysreflexia can be triggered by a: a. loud sound. b. distended bladder. c. leg cramp. d. sudden chilling.

ANS: B Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. REF: Page 1217 TOP: Rehabilitation

14. The nurse explains that the main goal of gerontological rehabilitation nurses (GRNs) is to provide rehabilitative care, and also to teach: a. restoration. b. prevention. c. adaptive skills. d. positive reinforcement.

ANS: B Teaching prevention is the dual goal of the GRN. Restoration, adaptive skills, and positive reinforcements are all part of rehabilitation. REF: Page 1213 TOP: Rehabilitation

3. The rehabilitation nurse instructs a paraplegic athlete that the rehabilitation experience will consist of: a. relearning former skills. b. learning to walk. c. learning new skills to adapt to a different lifestyle. d. developing muscle strength.

ANS: C The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patient's adaptation to a new lifestyle. REF: Page 1209 TOP: Rehabilitation

19. When assessing a brain-injured patient's inconsistent performance, the nurse recognizes that egocentricity increases the potential for: a. learning. b. depression. c. anger and frustration. d. intense concentration.

ANS: C Egocentricity of brain-injured patients makes them more prone to anger and frustration because they reference everything to themselves. REF: Pages 1218-1219 TOP: Rehabilitation

10. When planning care for children, the nurse uses a new concept that incorporates the family as equal partners in the rehabilitation process, which is called: a. child-centered care. b. systems-centered care. c. family-centered care. d. individual-centered care.

ANS: C Family-centered care is an evolving concept that uses the family as equal partners in the rehabilitation process. REF: Page 1212 TOP: Rehabilitation Step: Planning

34. The rehabilitation nurse prepares the family for when the patient with a brain injury begins to regain memory. The nurse explains that the patient will most likely become more: a. combative. b. angry. c. depressed. d. retiring.

ANS: C Generally, the more the memory improves, the more the patient becomes depressed. REF: Page 1219 TOP: Rehabilitation

9. The rehabilitation nurse explains that the difference between multidisciplinary and interdisciplinary is that in an interdisciplinary approach: a. each discipline makes its own goals for the patient. b. the entire team collaborates on the goals for the patient. c. the team is led by several members from different disciplines. d. cross-trained people are utilized who have functional ability in two or more disciplines.

ANS: C In the interdisciplinary approach, the team, led by the rehabilitation nurse, collaborates on the goals for the patient. REF: Pages 1209-1210 TOP: Rehabilitation

25. When speaking to a group of high school students, the rehabilitation nurse instructs that spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in: a. middle-aged men. b. older adult females. c. young males. d. young females.

ANS: C Individuals paralyzed by spinal cord injuries are primarily young males. REF: Page 1215 TOP: Rehabilitation

29. The rehabilitation nurse stresses to the family of a patient with a brain injury that difficult and painful rehabilitation will be required for at least: a. 1 to 2 years. b. 2 to 4 years. c. 5 to 10 years. d. 6 to 12 years.

ANS: C Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many require lifelong treatment and attention. REF: Page 1217 TOP: Rehabilitation

18. When changing the position of a patient with a spinal cord injury at T4, the nurse observes the first indication of an episode of autonomic dysreflexia, which is: a. nausea. b. pallor. c. goose bumps. d. dizziness.

ANS: C Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. In addition to high blood pressure, symptoms may include diaphoresis, shivering or goose bumps, flushing of the skin, and a severe pounding headache. REF: Page 1217 TOP: Rehabilitation

15. To reduce the incidence of postural hypotension in a patient with a spinal cord injury, the nurse should: a. monitor diastolic blood pressure closely. b. encourage the patient to sit in wheelchair in upright position. c. raise the head of the bed 45 degrees before transfer to a wheelchair. d. encourage adequate intake of fluids to expand fluid volume.

ANS: C Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. REF: Page 1217 TOP: Rehabilitation

4. The nurse who helps a family and a patient with a disability rejoice in the acquisition of the smallest new skill is following the rehabilitation philosophy of: a. resolving impairments. b. removing disabilities. c. increasing quality of life. d. returning to the community.

ANS: C Rehabilitation is based on the acquisition of new skills to better adapt and increase the quality of life. REF: Page 1208 TOP: Rehabilitation

1. The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing: a. holistic nursing. b. conscientious nursing. c. rehabilitation nursing. d. comprehensive nursing.

ANS: C Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable. REF: Page 1206 TOP: Rehabilitation

5. A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation nurse, "I'm sick of this interdisciplinary stuff! What is an occupational therapist going to do for me? Can she give me an "occupation?" The most helpful response the nurse could make is: a. "No, but the occupational therapist can show you how to enjoy some recreational activities." b. "Yes, in a way. The occupational therapist provides training that strengthens muscles you can still control." c. "Maybe. The occupational therapist recommends adaptive equipment that will make you more independent." d. "No, the voc-rehab counselor helps with employment. The occupational therapist helps train you for improved communication skills."

ANS: C The occupational therapist recommends adaptive equipment or helps in modifying skills to enhance independence. REF: Page 1210, Table 39-1 TOP: Rehabilitation

32. When a 33-year-old patient with a spinal cord injury says to the nurse, "I've let my family down. I don't know what to do," the nurse's best response is: a. "After your rehabilitation starts, you'll feel better." b. "You should be grateful you are alive." c. "What does this injury mean to you?" d. "Technological advances are changing the future for spinal cord injury victims."

ANS: C The patient should be encouraged to express his or her feelings about the disability. REF: Page 1216, NCP TOP: Rehabilitation

26. When assessing a patient with a cervical spinal injury (CSI), the rehabilitation nurse notes paralysis of the lower extremities as well as bladder and bowel incontinence. The nurse recognizes the injury as most likely occurring at the vertebral level of: a. C1 to C2. b. C3 to C4. c. C2 to C7. d. C4 to C7.

ANS: C The vertebral level of injury for a cervical cord is C2 to C7 if the patient is paraplegic and has lost control of bowel and bladder. REF: Pages 1214, 1215, Figure 39-2 TOP: Rehabilitation

11. The rehabilitation nurse stresses that the primary difference between rehabilitation of children and rehabilitation of adults is the child's: a. level of disability. b. body part involved. c. degree of disability. d. developmental potential.

ANS: D The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child. REF: Page 1212 TOP: Rehabilitation

27. The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. An example of an intervention that would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury is: a. encouraging large fluid intake. b. seeking spiritual support from a higher being. c. using the spouse as a support system. d. positioning to maintain alignment.

ANS: D Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability. REF: Page 1211 TOP: Rehabilitation