Adult Nursing - Chapter 10: Principles and Practices of Rehabilitation - PrepU
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? - "Encourage Kegel exercises." - "Encourage cranberry juice." - "Restrict client's fluids." - "Initiate a toileting schedule."
- "Restrict client's fluids."
The nurse working on a rehabilitation unit rotates a client's forearm so that the palm of the hand is facing down. The nurse documents this as which type of movement? - Inversion - Spination - Pronation - Eversion
- Pronation
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? - Specialty mattress - Ring or donut - Water bed - Gel flotation pad
- Ring or donut
Which term means to move away from the midline of the body? - Flexion - Extension - Abduction - Adduction
- Abduction
Which type of scale is used to systematically assess and quantify a client's risk for pressure ulcer? - Braden scale - FIM - PULSES profile - Barthel index
- Braden scale
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? - Uses the handrail on one side to go down the stairs - Lifts one leg by raising it off the ground - Keeps the head erect while combing the hair - Holds onto the furniture when walking in the house
- Holds onto the furniture when walking in the house
During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following? - Functional incontinence - Urge incontinence - Stress incontinence - Reflex incontinence
- Stress incontinence
A client with spinal cord injury has no awareness of the need to void. This type of incontinence is termed - functional incontinence. - reflex (neurogenic) incontinence. - toilet incontinence. - stress incontinence.
- reflex (neurogenic) incontinence.
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 I pressure ulcer - Stage II pressure ulcer - Stage IV pressure ulcer - Stage III pressure ulcer
- Stage II pressure ulcer
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 I pressure ulcer - Stage III pressure ulcer - Stage IV pressure ulcer - Stage II pressure ulcer
- Stage II pressure ulcer
When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply. - Diaphoresis - Edema - Anemia - Constipation - Sensory overload
- Diaphoresis - Edema - Anemia
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? - Enhanced perception of sensations - Slowed peristaltic activity - Increased moisture level - Diminished dermal collagen
- Diminished dermal collagen
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? - Lateral malleous - Scapula - Ischial tuberosity - Greater trochanter
- Ischial tuberosity
In which stage is a pressure ulcer considered a partial-thickness wound? - Stage IV - Stage II - Stage I - Stage III
- Stage II
During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following? - Urge incontinence - Functional incontinence - Stress incontinence - Reflex incontinence
- Stress incontinence
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 - 3.1 g/mL - 3.5 g/mL - 4.0 g/mL
- 2.5 g/mL
In which stage is a pressure ulcer considered a partial-thickness wound? - Stage I - Stage II - Stage III - Stage IV
- Stage II
Rotation of the forearm so that the palm of the hand is down is termed - eversion. - pronation. - inversion. - supination.
- pronation.
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching? - "I'll eat plenty of fruits and vegetables." - "I'll limit my intake of protein." - "I'll make sure that the bandage is wrapped tightly." - "My foot should feel cold."
- "I'll eat plenty of fruits and vegetables."
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? - 4.0 g/mL - 3.1 g/mL - 2.5 g/mL - 3.5 g/mL
- 2.5 g/mL
A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document? - Abduction - Rotation - Supination - Adduction
- Abduction
A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? - Stop any activity once fatigue occurs. - Group any heavy work to be done at the same time. - Avoid seeking help from others. - Emphasize areas of strengths.
- Emphasize areas of strengths.
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.) - Have an adequate intake of fiber containing foods. - Take a retention enema daily. - Have a fluid intake between 2 and 4 L/day. - Set a daily defecation time that is within 15 minutes of the same time every day. - Take a laxative daily.
- Have an adequate intake of fiber containing foods. - Have a fluid intake between 2 and 4 L/day. - Set a daily defecation time that is within 15 minutes of the same time every day.
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 - inversion. - supination. - palmar flexion. - opposition.
- opposition.
A client with spinal cord injury has no awareness of the need to void. This type of incontinence is termed - reflex (neurogenic) incontinence. - toilet incontinence. - functional incontinence. - stress incontinence.
- reflex (neurogenic) incontinence.
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? - Before bed - After breakfast - Upon arising - Around lunchtime
- 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 - Hemoglobin, 10.5 - Hematocrit, 43.5 - 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 - Crossing the client's ankles every 2 hours - Putting slippers on the client's feet - Placing hand rolls on the balls of each foot
- Attaching braces or splints to each foot and leg
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? - Pop-Tart - Bananas - Bran cereal - Applesauce
- Bran cereal
A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following? - Client leaks urine when coughing or sneezing. - Client experiences a strong perceived urge to void. - Client does not reach the toilet before experiencing voiding. - Client lacks the sensory awareness about the need to void.
- Client does not reach the toilet before experiencing voiding.
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 - Trochanter roll - Range-of-motion exercises - Protective boots
- Trochanter roll
To prevent footdrop, the client is positioned - in a sitting position with legs hanging off the side of the bed. - in a semi-sitting position in bed. - in a side-lying position. - to keep the feet at right angles to the leg.
- to keep the feet at right angles to the leg.
Which therapeutic exercise is done by the nurse without assistance from the client? - Isometric - Active - Passive - Resistive
- Passive
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." - "Do not delay the urge to move your bowels when it occurs." - "Eat plenty of fruits and vegetables throughout the day." - "Try to increase your activity level a bit more."
- "Keep your fluid intake to fewer than 2 liters per day."
A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate? - "Try to increase your activity level a bit more." - "Eat plenty of fruits and vegetables throughout the day." - "Keep your fluid intake to fewer than 2 liters per day." - "Do not delay the urge to move your bowels when it occurs."
- "Keep your fluid intake to fewer than 2 liters per day."
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 D - Vitamin E - Vitamin C - Calcium
- Vitamin C
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 the affected leg. - advance the unaffected leg. - advance both legs. - advance both crutches.
- advance both crutches.
Which type of scale is used to systematically assess and quantify a client's risk for pressure ulcer? - Barthel index - Braden scale - PULSES profile - FIM
- Braden scale
During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? - Stage III - Stage II - Stage IV - Stage I
- Stage IV
A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? - Moisture - Tissue perfusion - Skin color - Drainage
- Moisture
A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension? - Dry skin - Bradycardia - Flushing - Nausea
- Nausea
During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone? - Stage III - Stage IV - Stage I - Stage II
- Stage IV
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 - 15 minutes. - 30 minutes. - 45 minutes. - 1 hour.
- 1 hour.
Which disciplines should be consulted when caring for a client with a stage III heel ulcer? - Occupational therapy and infectious disease - A pillow or commercial heel protector to support the heels when the patient is supine - Plastic surgery and cardiology - Physical therapy and respiratory therapy
- A pillow or commercial heel protector to support the heels when the patient is supine
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 which equipment? - A hip-abductor pillow - A footboard - 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
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. - Client advances the cane at the same time he moves the affected leg forward. - Client keeps the cane fairly close to the body when ambulating. - Client bears down on the cane when he begins to swing the unaffected leg.
- Client moves the arm and leg on the same side together at the same time.
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? - Dressing - Bathing - Cooking - Grooming
- 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? - Incision and drainage - Debridement - Irrigation - Culture
- Debridement
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 stand up immediately. - Obtain a transfer board to ease the change. - Encourage the patient to take deep breaths. - Have the patient lie back down.
- 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? - Keeps the head erect while combing the hair - Holds onto the furniture when walking in the house - Lifts one leg by raising it off the ground - Uses the handrail on one side to go down the stairs
- Holds onto the furniture when walking in the house
After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown? - Constipation and lower extremity weakness - Dysarthria and left-sided visual deficit - Incontinence and right-sided hemiparesis - Right-sided visual deficit and dysarthria
- Incontinence and right-sided hemiparesis
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? - Tilt the chair back when moving the client. - Lift the client, do not slide them. - Encourage the client to slide up without assistance. - Use a donut device while the client is in the chair.
- Lift the client, do not slide them.
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? - Fatigue primarily results from physical demands. - Most care tasks required after discharge focus on the physical care. - Priority setting is helpful in dealing with the impact of the disability. - A loss of sexual functioning correlates with a loss of sexual feeling.
- Priority setting is helpful in dealing with the impact of the disability.
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 loss of sexual functioning correlates with a loss of sexual feeling. - Fatigue primarily results from physical demands. - Most care tasks required after discharge focus on the physical care.
- Priority setting is helpful in dealing with the impact of the disability.
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 glucose - Serum albumin - Prothrombin time - Sedimentation rate
- Serum albumin
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? - Swing-through - 3-point - 4-point - Swing-to
- Swing-through
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 - Bathing and feeding the client to decrease energy expenditure - Raising the head of the bed to maximize the client's lung inflation - Decreasing fluid intake to ease dependent edema
- Turning the client every 2 hours and providing a low-air-loss mattress
A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is - isometric. - resistive. - passive. - active-assistive.
- isometric.
A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply. - indwelling catheter output - family history of pressure ulcers - presence of pressure ulcers on the client - overall risk of developing pressure ulcers - potential areas of pressure ulcer development
- presence of pressure ulcers on the client - overall risk of developing pressure ulcers - potential areas of pressure ulcer development
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: - functional incontinence. - total incontinence. - reflex incontinence. - stress incontinence.
- stress incontinence.
Which therapeutic exercise is done by the nurse without assistance from the client? - Passive - Active - Isometric - Resistive
- Passive
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 the unaffected leg. - advance both crutches. - advance the affected leg. - advance both legs.
- advance both crutches.
A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is - active-assistive. - isometric. - passive. - resistive.
- isometric.
A nurse is describing the concept of rehabilitation to a group of families who have members in need of these services. Which statement would the nurse include in the description? - "Rehabilitation focuses on the person's abilities." - "Rehabilitation is primarily geared to those who can achieve independence." - "Rehabilitation negates the need for assistive devices." - "Rehabilitation begins once the patient is ready for discharge."
- "Rehabilitation focuses on the person's abilities."
A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? - Barthel Index - Patient Evaluation Conference System - PULSES profile - Functional Independence Measure
- Functional Independence Measure
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? - Potassium - Calcium - Protein - Phosphorous
- Protein
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 - Calcium - Phosphorous - Potassium
- Protein
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. - Eating - Cleaning - Bathing - Cooking - Toileting
- Eating - Bathing - Toileting
The nurse is initiating a bladder-training schedule for a patient. What intervention can be provided for optimal success? (Select all that apply.) - Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. - Give up to 3,000 mL of fluid daily. - Teach bladder massage to increase intra-abdominal pressure. - Require the patient to restrict fluid intake during the day to decrease voiding. - Administer a diuretic every morning.
- Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. - Give up to 3,000 mL of fluid daily. - Teach bladder massage to increase intra-abdominal pressure.
A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? - Functional Independence Measure - Barthel Index - PULSES profile - Patient Evaluation Conference System
- Functional Independence Measure
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 - Stage III - Stage IV - Stage I
- Stage II
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 - Nurse - Physician - Physical therapist
- Patient
A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? - Vigorously massage lotion over bony prominences. - Turn and reposition the client at least once every 8 hours. - Develop a written, individual turning schedule. - Slide the client, rather than lifting, when turning.
- Develop a written, individual turning schedule.
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 - Physician - Nurse - Physical therapist
- Patient
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 - Water - Zinc sulfate - Vitamin C
- Protein
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. - Take a laxative daily. - Take a retention enema daily. - Have an adequate intake of fiber containing foods. - Have a fluid intake between 2 and 4 L/day.
- 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.
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? - Use a donut device while the client is in the chair. - Encourage the client to slide up without assistance. - Lift the client, do not slide them. - Tilt the chair back when moving the client.
- Lift the client, do not slide them.
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 - In a sitting position with legs hanging off the side of the bed - In a semi-sitting position in bed - In a side-lying position
- To keep the feet at right angles to the leg
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 - Pillow between the legs - Protective boots - Range-of-motion exercises
- Trochanter roll
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 the client parks his car on the street - Whether pets are present in the home - Whether the client needs to navigate stairs routinely at home - Whether the client drives a car with a stick shift
- Whether the client needs to navigate stairs routinely at home
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 - Functional incontinence - Toilet incontinence - Reflex (neurogenic) incontinence
- Reflex (neurogenic) incontinence
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? - Putting slippers on the client's feet - Attaching braces or splints to each foot and leg - 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
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 - Adduction - Dorsiflexion - Pronation
- Opposition
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: - total incontinence. - reflex incontinence. - functional incontinence. - stress incontinence.
- stress incontinence.
A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should: - reduce the client's fluid intake. - turn him frequently. - perform passive range-of-motion (ROM) exercises. - encourage the client to use a footboard.
- turn him frequently.
A nurse is caring for a client who is documented to have orthostatic hypotension. The nurse anticipates finding which symptom upon assessment? - Dizziness - Hypertension - Bradycardia - Dry skin
- Dizziness
