Chapter 10 Principles and Practices of Rehabilitation

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."

The nurse is performing a skin assessment on a bedbound client 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

1 hour.

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

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 II

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

Stage III

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

Stress incontinence

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

Stress incontinence

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."

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

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)

- Set a daily defecation time that is within 15 minutes of the same time every day. - Have an adequate intake of fiber containing foods. - Have a fluid intake between 2 and 4 L/day.

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

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

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

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

The nurse is helping a client who experiences frequent constipation select meal choices for the day. Which food should the nurse encourage the client to order?

Bran cereal

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

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.

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

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.

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

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

Which nutritional deficiency may delay wound healing?

Lack of vitamin C

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

Lubricating the skin with a non-irritating lotion

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

Nutrition support and orthotics

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

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

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

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures.

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.

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

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and secondary to 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

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

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?

Serum albumin

In which stage is a pressure ulcer considered a partial-thickness wound?

Stage II

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

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

The patient

To prevent footdrop, what is the best way for the nurse to position the client?

To keep the feet at right angles to the leg

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

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

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

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.

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

"Restrict client's fluids."

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

Moisture

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, how should the nurse explain that the reason for holding a cane on the uninvolved side?

distribute weight away from the involved side.

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."

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

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."

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

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

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?

Reflex (neurogenic) incontinence

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

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."

The nurse is performing passive range-of-motion exercises with a client on a rehabilitation unit. The nurse takes the client's right hand and touches the thumb to each finger. Later, the nurse documents this range-of-motion activity as

opposition.

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.