Ch 10 rehab

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

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

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

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

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

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

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

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

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

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

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

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

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

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 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

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

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

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

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 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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