MS CH 10

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

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 clients who cannot control excreta because of physiologic or psychological impairment. Functional incontinence occurs in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and can not reach and use the toilet before soiling themselves.

A client is being taught to go down stairs using a cane. What action would the nurse instruct the patient to do first?

Step down with the affected leg. Explanation: When using a cane to go down stairs, first the patient would step down with the affected leg, then place the cane, and then place the unaffected extremity on the down step. The affected leg and cane should not be used simultaneously.

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, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

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

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

A diet high in carbohydrates Explanation: Wounds from which body fluids and protein drain place the patient in a catabolic state and predispose to hypoproteinemia and serious secondary infections. Protein deficiency must be corrected to promote the healing of the pressure ulcer. Carbohydrates are necessary to "spare" the protein and to provide an energy source.

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.

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.

The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe?

Gabapentin Explanation: The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?

Hyperemia Explanation: The initial sign of pressure is erythema (redness of the skin) caused by reactive hyperemia, which normally resolves in less than 1 hour. Unrelieved pressure results in tissue ischemia or anoxia. Eschar is a dry scab that forms over a healing ulcer.

Prostaglandins are chemical substances with what property?

Increase the sensitivity of pain receptors Explanation: Prostaglandins are believed to increase sensitivity to pain receptors by enhancing the pain-provoking effect of bradykinin. Endorphins and enkephalins reduce or inhibit transmission or perception of pain. Morphine and other opioid medications inhibit the transmission of noxious stimuli by mimicking enkephalin and endorphin.

A nurse is performing passive range of motion to a client's upper extremities. 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.

Which of the following is a physiologic response to pain?

Pallor Explanation: Physiologic responses to pain include pallor, tachycardia, diaphoresis, and hypertension.

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction. Explanation: Supporting the patient in a 30-degree side-lying position avoids pressure on the trochanter. In older adult patients, frequent small shifts of body weight may be effective. Placing a small rolled towel or sheepskin under a shoulder or hip allows a return of blood flow to the skin in the area on which the patient is sitting or lying. The towel or sheepskin is moved around the patient's pressure points in a clockwise fashion. A turning schedule can help the family keep track of the patient's turns.

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.

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?

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 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 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.

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.

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.

A type of therapeutic exercise, performed by a client, in which the muscle alternately 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 client 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 client. Active-assistive exercises are carried out by the client with the assistance of the therapist or the nurse.

A client is postoperative and has not taken her pain medication. The nurse is performing an assessment at the beginning of her shift and determines that sensitization has occurred. The first nursing intervention is to

Administer the prescribed intravenous opioid. Explanation: Sensitization occurs when the client waits too long to report pain and the pain is so intense that it is difficult to relieve. The first action of the nurse is to relieve the client's pain through administration of the prescribed intravenous opioid. Then the nurse can provide other alternative measures for pain relief. Once the pain is relieved, the nurse can educate the client about notifying the nurse when pain occurs. Naloxone is administered for opioid-induced respiratory depression. It is not needed in this client's situation.

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 Explanation: Clients with albumen concentrations <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 client at increased risk for impaired skin integrity.

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

Stage III Explanation: Clinically, in a stage III pressure ulcer, 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 non-blanchable erythema, tissue swelling, and congestion, and the client complains of discomfort.

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.

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.