Chapter 10
A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should highlight what salient risk factor for traumatic brain injury? A) Substance abuse B) Sports participation C) Anger mismanagement D) Lack of community resources
A. Substance abuse 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 of injury. This association exceeds the significance of sports participation, anger mismanagement, or lack of community resources.
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? A) Ineffective health maintenance B) Impaired physical mobility C) Disturbed sensory perception: Kinesthetic D) Ineffective role performance
B. Impaired physical mobility Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.
A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors? A) Decreased residual volume B) Urethral stenosis C) Increased bladder capacity D) Decreased muscle tone
D. Decreased muscle tone. Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.
The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply. A) Help the patient learn to apply and remove the orthosis. B) Teach the patient how to care for the skin that comes in contact with the orthosis. C) Assist in the initial fitting of the orthosis. D) Assist the patient in learning how to move the affected body part correctly. E) Collaborate with the physical therapist to set goals for care.
A, B, D, E In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely or if it is adjusted improperly. Nurses do not perform the initial fitting of orthoses.
You are the nurse creating the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patients nursing care plan? A) Maintain joint mobility. B) Refer to social services. C) Ambulate three times every day. D) Perform passive range of motion twice daily.
A. Maintain joint mobility. The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. The other listed actions are interventions, not goals.
A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care? A) Regular perineal care to prevent skin breakdown B) Kegel exercises to strengthen the pelvic floor C) Administration of hypotonic IV fluid D) Limited fluid intake to prevent incontinence
A. Regular perineal care to prevent skin breakdown Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.
An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs? A) To provide an optimal learning environment with minimal distractions B) To describe the evidence base for any chosen interventions C) To help the patient become aware of the requirements of assisted-living centers D) To ensure that the patient is able to perform self-care without any aid from caregivers
A. To provide an optimal learning environment with minimal distractions. The nurses role is to provide an optimal learning environment that minimizes distractions. Describing the evidence base is not a priority, though nursing actions should indeed be evidence-based. Assisted- living facilities are not relevant to most patients. Absolute independence in ADLs is not an appropriate goal for every patient.
You are the nurse caring for an elderly patient who has been on a bowel training program due to the neurologic effects of a stroke. In the past several days, the patient has begun exhibiting normal bowel patterns. Once a bowel routine has been well established, you should avoid which of the following? A) Use of a bedpan B) Use of a padded or raised commode C) Massage of the patients abdomen D) Use of a bedside toilet
A. Use of a bedpan Use of bedpans should be avoided once a bowel routine has been established. An acceptable alternative to a private bathroom is a padded commode or bedside toilet. Massaging the abdomen from right to left facilitates movement of feces in the lower tract.
You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position? A) Use of an abduction pillow between the patients legs B) Alignment of the head with the spine using a pillow C) Support of the lower back with a small pillow D) Placement of trochanter rolls under the greater trochanter
A. Use of an abduction pillow between the patient's legs. Abduction pillows can be used to keep the hip in correct alignment if precautions are warranted following hip replacement. Trochanter rolls and back pillows do not achieve this goal.
You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care? A) Advice from his family B) Appropriate assistive devices C) A personal health care aide D) An assisted-living environment
B. Appropriate assistive devices. Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.
You are the rehabilitation nurse caring for a 25-year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently? A) Complete a physical assessment. B) Evaluate the patients positioning. C) Plan nursing interventions. D) Assist the patient to ambulate.
B. Evaluate the patient's positioning During each patient contact, the nurse evaluates the patients position and assists the patient to achieve and maintain proper positioning and alignment. The nurse does not complete a physical assessment during each patient contact. Similarly, the nurse does not plan nursing interventions or assist the patient to ambulate each time the nurse has contact with the patient.
A nurse has been asked to become involved in the care of an adult patient in his fifties who has experienced a new onset of urinary incontinence. During what aspect of the assessment should the nurse explore physiologic risk factors for elimination problems? A) Physical assessment B) Health history C) Genetic history D) Initial assessment
B. Health History The health history is used to explore bladder and bowel function, symptoms associated with dysfunction, physiologic risk factors for elimination problems, perception of micturition (urination or voiding) and defecation cues, and functional toileting abilities. Elimination problems are not explored in the other listed aspects of assessment.
A nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care? A) Extended rehabilitation care B) Independent living C) Acute-care center treatment D) State institutions that provide care for life
B. Independent living There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not describe extended rehabilitation care, acute-care center treatment, or state institutions because these are not increasing in importance.
The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid? A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads
B. Indwelling catheter Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing? A) Passive B) Isometric C) Resistive D) Abduction
B. Isometric Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.
A patient is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system? Using this system achieves what goal of the patients care? A) Minimizing costs of the patients care B) Maintaining continuity of the patients care C) Maintain the nursing care plan between diverse sites D) Keeping the primary care provider informed
B. Maintaining continuity of the patient's care. A referral system maintains continuity of care when the patient is transferred to the home or to a long- term care facility. The interests of cost and of keeping the primary care provider informed are not primary. The nursing plan is likely to differ between sites.
An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process? A) Most-responsible nurse B) Patient C) Patients family D) Primary care physician
B. Patient The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.
A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process? A) To provide 24-hour, collaborative care for the patient B) To restore the patients ability to function independently C) To minimize the patients time spent in acute care settings D) To promote rapport between caregivers and the patient
B. To restore the patient's ability to function independently. The goal of rehabilitation is to restore the patients ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizing time in acute care are not central goals of rehabilitation.
An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility? A) Motivate the patient to walk in the afternoon rather than the morning. B) Encourage the patient to push through the pain in order to gain further mobility. C) Administer an analgesic as ordered to facilitate the patients mobility. D) Have another person with osteoarthritis visit the patient.
C. Administer an analgesic as ordered to facilitate the patient's mobility. At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to push through the pain.
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency? A) Hemoglobin B) Bilirubin C) Albumin D) Cortisol
C. Albumin Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than 3 g/mL are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.
A nurse is caring for a patient undergoing rehabilitation following a snowboarding accident. Within the interdisciplinary team, the nurse has been given the responsibility for coordinating the patients total rehabilitative plan of care. What nursing role is this nurse performing? A) Patient educator B) Caregiver C) Case manager D) Patient advocate
C. Case manager. When the nurse coordinates the patients total rehabilitative plan of care, the nurse is functioning as a case manager. The nurse must coordinate services provided by all of the team members. The other answers are incorrect.
A home care nurse performs the initial visit to a patient who is soon being discharged from a rehabilitation facility. This initial visit is to assess what the patient can do and to see what he will need when discharged home. What does this help ensure for the patient? A) Social relationships B) Family assistance C) Continuity of care D) Realistic expectations
C. Continuity of care. A home care nurse may visit the patient in the hospital, interview the patient and the family, and review the ADL sheet to learn which activities the patient can perform. This helps ensure that continuity of care is provided and that the patient does not regress, but instead maintains the independence gained while in the hospital or rehabilitation setting. This initial visit does not ensure social relationships, family assistance, or realistic expectations.
A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. You are the nurse planning the patients care. Who will the patients condition affect? A) Himself B) His wife and any children that still live at home C) Him and his entire family D) No one, provided he has a complete recovery
C. Him and his entire family. Patients and families who suddenly experience a physically disabling event or the onset of a chronic illness are the ones who face several psychosocial adjustments, even if the patient recovers completely.
A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient? A) Keep a record of when the incontinence occurs. B) Perform clean intermittent self-catheterization. C) Perform Kegel exercises four to six times per day. D) Wear a protective undergarment to address this age-related change.
C. Perform Kegel exercises four to six times per day. For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.
You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? A) Turn and reposition the patient a minimum of every 8 hours. B) Vigorously massage lotion into bony prominences. C) Post a turning schedule at the patients bedside and ensure staff adherence. D) Slide, rather than lift, the patient when turning.
C. Post a turning schedule at the patient's bedside and ensure staff adherence. A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients 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 patient, the nurse should lift, rather than slide, the patient to avoid shearing.
The rehabilitation team has reaffirmed the need to maximize the independence of a patient in rehabilitation. When working toward this goal, what action should the nurse prioritize? A) Encourage families to become paraprofessionals in rehabilitation. B) Delegate care planning to the patient and family. C) Recognize the importance of informal caregivers. D) Make patients and families to work together.
C. Recognize the importance of informal caregivers. In working toward maximizing independence, nurses affirm the patient as an active participant and recognize the importance of informal caregivers in the rehabilitation process. Nurses do not encourage families to become paraprofessionals in rehabilitation. The patient and family are central, but care planning is not their responsibility. Nurses do not make patients and families work together.
A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the patient is admitted to a rehabilitation facility? A) The ability to perform ADLs may be the key to dependence. B) The ability to perform ADLs is essential to living in a group home. C) The ability to perform ADLs may be the key to reentry into the community. D) The ability to perform ADLs is necessary to function in an assisted-living situation.
C. The ability to perform ADLs may be the key to reentry into the community. An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.
You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action? A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.
C. You know that the risk for pressure ulcers is directly related to the duration of immobility. The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the patient does not want to prevent pressure ulcers.
You are the nurse providing care for a patient who has limited mobility after a stroke. What would you do to assess the patient for contractures? A) Assess the patients deep tendon reflexes (DTRs). B) Assess the patients muscle size. C) Assess the patient for joint pain. D) Assess the patients range of motion.
D. Assess the patients range of motion. Each joint of the body has a normal range of motion. To assess a patient for contractures, the nurse should assess whether the patient can complete the full range of motion. Assessing DTRs, muscle size, or joint pain do not reveal the presence or absence of contractures.
An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV
D. IV Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.
You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the- knee amputations. How can you anticipate that the patient will respond to this news? A) The patient will go through the stages of grief over the next week to 10 days. B) The patient will progress sequentially through five stages of the grief process. C) The patient will require psychotherapy to process his grief. D) The patient will experience grief in an individualized manner.
D. The patient will experience grief in an individualized manner. Loss of limb is a profoundly emotional experience, which the patient will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the patients grief. The patient may or may not benefit from psychotherapy.
The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patients electronic health record reveals that the patient usually defers her self- care to family members or members of the care team. What should the nurse include as an initial goal when planning this patients subsequent care? A) The patient will demonstrate independent self-care. B) The patients family will collaboratively manage the patients care. C) The nurse will delegate the patients care to a nursing assistant. D) The patient will participate in a life skills program.
A. The patient will demonstrate independent self care. An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patients care, the patients care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.
You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site.
B. Patient avoids placing her body weight on the healing site. The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.
The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation? A) Stimulating the patients desire to ambulate B) Assessing the patients understanding of ambulation C) Helping the patient perform frequent exercise D) Setting realistic expectations
C. Helping the patient perform frequent exercise. Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulation whether with brace, walker, cane, or crutches the patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation.
You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient? A) Whole wheat macaroni with cheese B) Skim milk, oatmeal, and whole wheat toast C) Steak, baked potato, spinach and strawberry salad D) Eggs, hash browns, coffee, and an apple
C. Steak, baked potato, spinach and strawberry salad. The patient should be encouraged to eat foods high in protein, carbohydrates and vitamins A, B, and C. A meal of steak, baked potato, spinach and strawberry salad best exemplifies this dietary balance.
The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? A) The patients elbows B) The soles of the patients feet C) The patients heels D) The patients knees
C. The patient's heels Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.
A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize? A) Liaising with the patients insurer to describe the patients successes. B) Teaching the patient about the pathophysiology of her functional deficits. C) Eliciting ways to get the patient to express a positive attitude. D) Appraising the familys involvement in the patients ADLs.
D. Appraising the family's involvement in the patient's ADLs. The nurse should also be aware of the patients medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the familys involvement in the patients ADLs. It is not normally necessary to teach the patient about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.
18. You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following? A) Dressing B)Bathing C) Feeding D) Meal preparation
D. Meal preparation Instrumental activities of daily living (IADLs) include grocery shopping, meal preparation, housekeeping, transportation, and managing finances. Activities of daily living (ADLs) include bathing dressing, feeding, and toileting.
A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use? A) A cane B) Crutches C) A two-wheeled walker D) Parallel bars
D. Parallel bars After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.
As a member of the rehabilitation team, the nurse is conscious of the need to perform the nursing role in collaboration with the other members of the team. Which of the following variables has the greatest bearing on the nurses choice of actions and interventions during rehabilitative care? A) The skills of the other members of the team B) The circumstances of the patient C) The desires of the patients family D) The nurses education and experience level
B. The circumstances of the patient. Nurses assume an equal or, depending on the circumstances of the patient, a more critical role than other members of the health care team in the rehabilitation process. The nurses role on the rehabilitation team does not depend primarily on other members of the team, the family's desires, or the nurses education level.
