Ch 39: Rehabilitation Nursing, Ch 38: Long-Term Care

34. Two unique members of the caregiving team in a long-term care facility are the aide/technician and the assistant.

ANS: certified medication, restorative nursing These two members of the care team are unique to the long-term care facility. Both have had extra training over and above that of the Certified Nursing Assistant. REF: Page 1200 TOP: Long-term caregiving team

39. The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in his practice is said to be .

ANS: culturally competent A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice. REF: Page 1208 TOP: Culture

33. When a resident who is a Muslim becomes concerned about his religiously dictated dietary requirements, the nurse may refer this concern to the long-term care department.

ANS: dietary Long-term facilities take into consideration the patients' individual needs, including diet preferences. The dietary department is usually able to meet most requests. REF: Page 1194 TOP: Ethnic considerations

37. The rehabilitation nurse assesses localized edema around the knee of a patient with paraplegia. The nurse suspects that this is the first sign of .

ANS: heterotopic ossification Heterotopic ossification is a bony growth in joints of spinal cord injury patients that ultimately limits range of motion. REF: Page 1217 TOP: Rehabilitation

32. The nurse explains to a patient that shopping, using a phone, and administering his own medications are classified as activities of daily living.

ANS: instrumental IADLs are more complex skills than ADLs and indicate a higher level of independent functioning. REF: Page 1197 TOP: Instrumental activities of daily living (IADLs)

38. A child who was struck by a car and suffered a closed head injury was unconscious for 24 hours before waking. The nurse recognizes this as a brain injury.

ANS: moderate A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury. REF: Page 1218 TOP: Rehabilitation

30. The rehabilitation nurse tells the patient that a truly successful quality rehabilitation program will result in a patient who: a. continually strives to gain greater independence. b. becomes employed. c. views himself realistically. d. reenters the community.

ANS: A A rehabilitation program can be considered a success if the patient is stimulated to continue to increase his independence, whether or not he becomes employed or reenters the community. REF: Page 1209 TOP: Rehabilitation

13. The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also the debilitating factor of: a. advancing age. b. reduced ability to learn. c. limited energy. d. eroded interest level.

ANS: A Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. REF: Page 1213 TOP: Rehabilitation

29. When a patient asks why he must be transferred to a subacute unit from the hospital, the nurse replies that: a. reimbursement guidelines limit adults' stays in an acute setting. b. the physician can oversee care more closely in a subacute setting. c. financial restrictions of insurance limit time spent in an acute care setting. d. cost and services at the acute care setting are the same.

ANS: A In the acute care setting, strict rules about length of stay and limitations in cost reimbursement limit the amount of time adults can be hospitalized. These strict reimbursement rules for acute care do not, however, apply to subacute care provided in a skilled nursing facility setting. REF: Page 1198 TOP: Nursing process

31. The rehabilitation nurse recognizes that the majority of head injuries show no abnormal neurological findings and experience no loss of consciousness, which categorizes them as: a. mild. b. moderate. c. severe. d. catastrophic.

ANS: A Mild brain injury is characterized by no loss of consciousness and no abnormal neurological findings. REF: Page 1218 TOP: Rehabilitation

28. The long-term care facility nurse should make rounds and monitor residents for safety every: a. 2 hours. b. 4 hours. c. 6 hours. d. shift.

ANS: A Nursing interventions related to long-term care include making rounds and monitoring for resident safety every 2 hours. REF: Page 1203 TOP: Nursing process

12. The LVN/LPN helps an 82-year-old patient recovering from a hip replacement understand that the remainder of her rehabilitation phase will not be spent in the acute hospital setting, but in a(n): a. subacute care unit. b. assisted living center. c. adult day care center. d. long-term care facility (nursing home).

ANS: A Subacute units have a stronger rehabilitative focus. REF: Pages 1198-1199 TOP: Subacute

20. Although the Occupational Safety and Health Act (OSHA) increases the cost of care, it also specifies the requirements for safe: a. environment. b. medication administration. c. food preparation. d. ambulation and transportation.

ANS: A The OSHA guidelines significantly increase costs, but they also ensure a safe environment, which is mandatory today. REF: Page 1201 TOP: Long-term care

30. The LPN/LVN performs which function(s) when working as a staffing coordinator of a home health agency? Select all that apply. a. Scheduling appropriate care providers b. Reviewing documentation c. Verifying financial coverage d. Making referrals e. Performing comprehensive assessments

ANS: A, B, C Scheduling care providers, reviewing documentation, and verifying financial coverage are among the duties of the staffing coordinator. Making referrals and performing comprehensive assessments are duties of the RN. REF: Page 1200 TOP: Staffing coordinator

36. The nurse explains that the Americans with Disabilities Act of 1990 defines a person as disabled if which criteria are met? (Select all that apply.) a. The person has a physical or mental disability. b. The person is limited in a major life activity. c. The person has a medical record of the impairment. d. The person is unemployed. e. The person needs assistance in completion of ADLs.

ANS: A, B, C The definition is that a disabled person may have a physical or mental disability that limits him or her in a major life activity and has a medical record of that disability. DIF: Cognitive Level: Comprehension REF: Pages 1207-1208 OBJ: 4 TOP: Americans with Disabilities Act (ADA)

35. What are the characteristics of chronic illness as compiled by the Commission on Chronic Illness? (Select all that apply.) a. The illness requires specialized training for rehabilitation. b. The illness cannot be overcome. c. The illness is permanent. d. The illness has an unpredictable outcome. e. The illness leaves a residual disability.

ANS: A, C, E The Commission listed among the characteristics of chronic illness that chronic illness requires specialized, specific training for rehabilitation; the effects of the illness are permanent; and the illness leaves a residual disability. REF: Page 1207 TOP: Rehabilitation

8. The rehabilitation nurse outlines the need for comprehensive rehabilitation for better functional outcomes for the patient. A comprehensive rehabilitation plan of care must be implemented following admission within: a. 12 hours. b. 24 hours. c. 3 days. d. 1 week.

ANS: B A comprehensive rehabilitation plan is initiated within 24 hours of admission to the rehabilitation service. REF: Page 1211 TOP: Rehabilitation

22. The nurse recognizes that a handicap differs from impairment in that a handicap is: a. a loss of function. b. a disadvantage that limits a particular individual in his or her usual role performance. c. a specific restriction to perform an activity or role. d. usually of a physical nature.

ANS: B A handicap is a disadvantage for a given individual from an impairment that limits his or her role performance. A particular handicap for one person might not pose any handicap for another with the same disability. REF: Page 1207 TOP: Rehabilitation

7. When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on the goal of: a. returning to normal. b. independence. c. employment. d. promotion of health.

ANS: B A rehabilitation nurse must help the patient focus on increasing independence. REF: Page 1209 TOP: Rehabilitation

10. The nurse differentiates the services of a long-term care facility from that of an assisted living facility, which supplies residents with: a. skilled nursing care. b. personal care services. c. weekly visits by the staff physician. d. intensive rehabilitation services.

ANS: B Assisted living is a type of residential care setting where the resident receives personal care services. REF: Pages 1197-1198 TOP: Long-term care

20. When caring for a 32-year-old Hispanic male who has become disabled, the rehabilitation team will set the priority of treatment goals based on the: a. difficulty of the language barrier. b. cultural significance of the disability. c. depth of the patient's support system. d. attitude toward rehabilitation.

ANS: B Culture defines the significance of disease and disability. Although all of the options must be addressed, the significance of the disability has highest priority. REF: Page 1208 TOP: Rehabilitation

23. To decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury, the nurse will: a. massage the patient's legs daily. b. perform passive range-of-motion exercises. c. encourage frequent warm baths. d. allow the patient's legs to dangle for a period of 10 minutes several times a day.

ANS: B DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT. REF: Page 1207 TOP: Rehabilitation

21. When pointing out the economic significance of rehabilitation, the rehabilitation nurse uses a chart to show that for every dollar spent on rehabilitation, the amount saved is: a. $2. b. $3. c. $4. d. $5.

ANS: B For every $1 spent on rehabilitation, $3 is saved in public funds that would have been used for residential care of the disabled. REF: Page 1208 TOP: Rehabilitation

25. In a long-term care facility, the nurse takes an active part in formulating the resident's plan of care, which is revised every: a. week. b. 90 days. c. month. d. six months.

ANS: B In long-term care, the resident's plan of care is reviewed by the interdisciplinary team every 90 days for resolution of problems or revision of goals and interventions. REF: Page 1202 TOP: Nursing process

11. The nurse informs an older adult couple considering a continuing care retirement community (CCRC) that these facilities offer a complete range of health care services from independent living to 24-hour skilled nursing and that a contract with a CCRC is: a. limited to people who are relatively unimpaired. b. usually a lifetime commitment. c. an acceptable tax shelter. d. on a month-to-month basis.

ANS: B In most cases, signing a contract with a CCRC is a lifetime commitment. REF: Page 1198 TOP: Long-term care

1. To help the resident preserve a meaningful quality of life in a long-term care setting, the nurse will implement a(n): a. patient care plan. b. individualized approach. c. psychologically approved approach. d. physician-approved approach.

ANS: B Long-term care services are provided in a variety of settings and offer a broad spectrum of services. The specific setting used and services offered are based on the individual and unique needs of each patient. A patient-centered approach is needed to achieve and maintain an individualized approach and to assist the patient in preserving a meaningful quality of life. REF: Page 1193 TOP: Long-term care Step: Planning

17. The nurse instructs the mother of a 5-year-old who sustained a mild brain injury that although all neurological evaluations are normal, her child may exhibit postconcussive syndrome, which is characterized by: a. convulsions and high fever. b. irritability and memory deficits. c. muscular twitching and muscle pain. d. paresis of limbs.

ANS: B Mild brain injury is characterized by brief or no loss of consciousness. This type constitutes the majority of head injuries. Neurological examinations are often normal. Postconcussive syndrome can persist for months, years, or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed, and memory, understanding, learning, and perceptual difficulties. REF: Page 1218 TOP: Rehabilitation

6. Approximately 50% of the rehabilitation nurse's contribution to the rehabilitation effort is having a broad knowledge base of the pathophysiology modalities of rehabilitation. The other major contribution is: a. implementation. b. encouragement. c. evaluation. d. cooperation.

ANS: B Nurses practicing in the area of rehabilitation believe that individuals with functional disabilities have an intrinsic worth that transcends their disabilities. Rehabilitation nursing is an attitude in addition to a set of specialized knowledge and skills. Estimates are that 50% of rehabilitation nursing is know-how; the other 50% is simple open-minded encouragement. REF: Page 1210 TOP: Rehabilitation

27. The long-term care facility nurse recognizes that visiting the resident, changing his or her position, assessing for incontinence, providing skin care, and offering fluids are part of the nurse's responsibility. These interventions are initiated to provide: a. continuity. b. safety. c. prevention. d. reassurance.

ANS: B Nursing interventions basic to long-term care include monitoring for resident safety. REF: Page 1203 TOP: Nursing process

28. The nurse teaches a patient that autonomic dysreflexia can be triggered by a: a. loud sound. b. distended bladder. c. leg cramp. d. sudden chilling.

ANS: B Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. REF: Page 1217 TOP: Rehabilitation

14. The nurse explains that the main goal of gerontological rehabilitation nurses (GRNs) is to provide rehabilitative care, and also to teach: a. restoration. b. prevention. c. adaptive skills. d. positive reinforcement.

ANS: B Teaching prevention is the dual goal of the GRN. Restoration, adaptive skills, and positive reinforcements are all part of rehabilitation. REF: Page 1213 TOP: Rehabilitation

7. The LVN/LPN informs the home health patient that the home health care RN provides many services, but is mainly employed by the home health agency in the capacity of: a. daily caregiver. b. care administrator. c. creator of policy and protocols. d. liaison between the agency and the state board.

ANS: B The RN is also employed by the home health care agency as an administrator. REF: Page 1196 TOP: Home health

13. The nurse explains that people in a long-term care facility are referred to as: a. patients because they will be receiving acute care. b. residents because the facility has become their home. c. patients because they seek professional medical services. d. customers because they are purchasing care service.

ANS: B The older adult in a long-term care facility is referred to as a resident to reinforce the home-like environment. REF: Page 1199 TOP: Long-term care

26. The nurse recognizes that an ongoing assessment will help set priorities in the nursing care plan of a long-term care resident. Timely assessments allow the planning process to be: a. based on the patient's disease process. b. patient-centered. c. preferential. d. categorized.

ANS: B The planning process must be patient-centered. REF: Page 1203 TOP: Nursing process Step: Planning

31. The LPN/LVN suggests to the RN that the nursing care plan be modified to include referral to an adult day care center for which benefit(s)? (Select all that apply.) a. Overnight care b. Respite care for the family c. Social interaction for the patient d. Mental stimulation for the patient e. Supporting maintenance of the ADLs

ANS: B, C, D, E Overnight care is usually not offered from a day care center. REF: Pages 1196-1197 TOP: Adult day care

3. The rehabilitation nurse instructs a paraplegic athlete that the rehabilitation experience will consist of: a. relearning former skills. b. learning to walk. c. learning new skills to adapt to a different lifestyle. d. developing muscle strength.

ANS: C The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patient's adaptation to a new lifestyle. REF: Page 1209 TOP: Rehabilitation

24. The nurse follows guidelines set out by OBRA when documenting a summary including vital signs and weights, which is required every: a. day. b. week. c. month. d. year.

ANS: C A summary, including vital signs and weights, is only required on a monthly basis. REF: Page 1202 TOP: Long-term care

9. The nurse suggests to a family caring for a member with early Alzheimer's disease in their home that they investigate the services of an adult day care center because such centers: a. will take patient out on recreational outings. b. can provide daily hygiene. c. expand social interaction. d. are free to the public.

ANS: C Adult day care centers are open a large part of the day and offer several modalities to enhance social interaction and also give the family respite. REF: Pages 1196-1197 TOP: Adult day care

19. When assessing a brain-injured patient's inconsistent performance, the nurse recognizes that egocentricity increases the potential for: a. learning. b. depression. c. anger and frustration. d. intense concentration.

ANS: C Egocentricity of brain-injured patients makes them more prone to anger and frustration because they reference everything to themselves. REF: Pages 1218-1219 TOP: Rehabilitation

10. When planning care for children, the nurse uses a new concept that incorporates the family as equal partners in the rehabilitation process, which is called: a. child-centered care. b. systems-centered care. c. family-centered care. d. individual-centered care.

ANS: C Family-centered care is an evolving concept that uses the family as equal partners in the rehabilitation process. REF: Page 1212 TOP: Rehabilitation Step: Planning

34. The rehabilitation nurse prepares the family for when the patient with a brain injury begins to regain memory. The nurse explains that the patient will most likely become more: a. combative. b. angry. c. depressed. d. retiring.

ANS: C Generally, the more the memory improves, the more the patient becomes depressed. REF: Page 1219 TOP: Rehabilitation

8. The family caring for an older adult in their home feels that they need assistance from a hospice service. The nurse instructs them that service can be initiated by: a. family request. b. patient request. c. medical certification. d. referral by a hospice nurse.

ANS: C Hospice agencies provide care at the end of life. Medical certification is required for terminal care. REF: Page 1196 TOP: Hospice

9. The rehabilitation nurse explains that the difference between multidisciplinary and interdisciplinary is that in an interdisciplinary approach: a. each discipline makes its own goals for the patient. b. the entire team collaborates on the goals for the patient. c. the team is led by several members from different disciplines. d. cross-trained people are utilized who have functional ability in two or more disciplines.

ANS: C In the interdisciplinary approach, the team, led by the rehabilitation nurse, collaborates on the goals for the patient. REF: Pages 1209-1210 TOP: Rehabilitation

25. When speaking to a group of high school students, the rehabilitation nurse instructs that spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in: a. middle-aged men. b. older adult females. c. young males. d. young females.

ANS: C Individuals paralyzed by spinal cord injuries are primarily young males. REF: Page 1215 TOP: Rehabilitation

4. The nurse confirms that the cost of caring for a relatively unimpaired older adult in a private home is approximately what fraction of the cost of placing him or her in a long-term care facility? a. 1/4 b. 1/3 c. 1/2 d. 2/3

ANS: C It costs approximately half as much to care for an older adult at home as it would cost in a long-term care facility. REF: Page 1195 TOP: Long-term care

29. The rehabilitation nurse stresses to the family of a patient with a brain injury that difficult and painful rehabilitation will be required for at least: a. 1 to 2 years. b. 2 to 4 years. c. 5 to 10 years. d. 6 to 12 years.

ANS: C Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many require lifelong treatment and attention. REF: Page 1217 TOP: Rehabilitation

17. When planning care in a long-term care facility, the nurse is aware of resident's rights as Omnibus Budget Reconciliation Act (OBRA) defines the requirements for: a. nursing care. b. nutritional support. c. quality of care. d. staffing requirements.

ANS: C OBRA defines requirements for the quality of care given to residents of long-term care facilities. REF: Page 1201 TOP: Long-term care Step: Planning

6. The nurse clarifies to the family of a patient that the role of the LPN/LVN in the home care setting is to be a resource person and to evaluate the care provided to the patient by: a. the family. b. other licensed care providers. c. nonlicensed staff. d. the physician.

ANS: C One of the roles of the LPN/LVN in the home care setting may be to evaluate the care provided by CNAs, HHAs, homemakers, and personal care attendants. REF: Page 1196 TOP: Home health

18. When changing the position of a patient with a spinal cord injury at T4, the nurse observes the first indication of an episode of autonomic dysreflexia, which is: a. nausea. b. pallor. c. goose bumps. d. dizziness.

ANS: C Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. In addition to high blood pressure, symptoms may include diaphoresis, shivering or goose bumps, flushing of the skin, and a severe pounding headache. REF: Page 1217 TOP: Rehabilitation

15. To reduce the incidence of postural hypotension in a patient with a spinal cord injury, the nurse should: a. monitor diastolic blood pressure closely. b. encourage the patient to sit in wheelchair in upright position. c. raise the head of the bed 45 degrees before transfer to a wheelchair. d. encourage adequate intake of fluids to expand fluid volume.

ANS: C Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. REF: Page 1217 TOP: Rehabilitation

4. The nurse who helps a family and a patient with a disability rejoice in the acquisition of the smallest new skill is following the rehabilitation philosophy of: a. resolving impairments. b. removing disabilities. c. increasing quality of life. d. returning to the community.

ANS: C Rehabilitation is based on the acquisition of new skills to better adapt and increase the quality of life. REF: Page 1208 TOP: Rehabilitation

1. The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing: a. holistic nursing. b. conscientious nursing. c. rehabilitation nursing. d. comprehensive nursing.

ANS: C Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable. REF: Page 1206 TOP: Rehabilitation

5. The nurse recognizes that services provided by home health care agencies are aimed at: a. self-care. b. assisted living. c. rehabilitation. d. improved function.

ANS: C Services provided by home health care agencies are aimed at rehabilitation. REF: Page 1195 TOP: Home health

18. The Health Care Financing Administration (HCFA) conducts unannounced institutional surveys annually to assess the quality of life for the patients, which is reported to: a. various licensing boards. b. facility administrators. c. the public. d. the U.S. Department of Health and Human Services.

ANS: C Surveyors are required by law to visit the long-term care facility unannounced, on an annual basis and as needed, and the report is made public. REF: Page 1201 TOP: Long-term care

22. When the LVN/LPN completes the Resident Assessment Instrument (RAI), it must have the: a. Minimum Data Set (MDS) and the signature of the physician. b. Resident Assessment Protocols (RAPs) and the drug list. c. Minimum Data Set, Resident Assessment Protocols, and the RN's signature. d. Resident Assessment Protocols and the signature of the administrator.

ANS: C The RAI must be signed by the RN and contain the RAPs and MDS. REF: Page 1202 TOP: Long-term care

2. The home health nurse is assisting a family to select a long-term care facility for an 80-year-old widow in good health who no longer drives, loves to play cards, can ambulate with a walker, and is oriented. The best selection for this patient would be: a. subacute unit setting. b. long-term care facility (nursing home). c. assisted living center. d. continuing care retirement center (CCRC).

ANS: C The assisted living center provides meals, transportation, social interaction, and a home-like quality without the intrusion of the medical model. The patient's age does not make her a reasonable candidate for a CCRC. The patient does not require acute skilled nursing care. REF: Page 1197 TOP: Long-term care

15. In the long-term care facility, health care professionals work together to meet the needs of older adults and to go over the care plan with the resident and family members. This approach is called a(n): a. team approach. b. individualized approach. c. interdisciplinary approach. d. outgoing approach.

ANS: C The long-term care facility is an interdisciplinary setting. REF: Page 1199 TOP: Long-term care

5. A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation nurse, "I'm sick of this interdisciplinary stuff! What is an occupational therapist going to do for me? Can she give me an "occupation?" The most helpful response the nurse could make is: a. "No, but the occupational therapist can show you how to enjoy some recreational activities." b. "Yes, in a way. The occupational therapist provides training that strengthens muscles you can still control." c. "Maybe. The occupational therapist recommends adaptive equipment that will make you more independent." d. "No, the voc-rehab counselor helps with employment. The occupational therapist helps train you for improved communication skills."

ANS: C The occupational therapist recommends adaptive equipment or helps in modifying skills to enhance independence. REF: Page 1210, Table 39-1 TOP: Rehabilitation

32. When a 33-year-old patient with a spinal cord injury says to the nurse, "I've let my family down. I don't know what to do," the nurse's best response is: a. "After your rehabilitation starts, you'll feel better." b. "You should be grateful you are alive." c. "What does this injury mean to you?" d. "Technological advances are changing the future for spinal cord injury victims."

ANS: C The patient should be encouraged to express his or her feelings about the disability. REF: Page 1216, NCP TOP: Rehabilitation

26. When assessing a patient with a cervical spinal injury (CSI), the rehabilitation nurse notes paralysis of the lower extremities as well as bladder and bowel incontinence. The nurse recognizes the injury as most likely occurring at the vertebral level of: a. C1 to C2. b. C3 to C4. c. C2 to C7. d. C4 to C7.

ANS: C The vertebral level of injury for a cervical cord is C2 to C7 if the patient is paraplegic and has lost control of bowel and bladder. REF: Pages 1214, 1215, Figure 39-2 TOP: Rehabilitation

19. When a 48-year-old long-term care facility resident expresses concern over the cost of care that has used up his assets, the nurse suggests that to cover the continued cost of living in a long-term facility, the resident should apply for: a. Medicare. b. hospitalization insurance. c. Medicaid. d. public health funds.

ANS: C When adults have used all of their assets, they may then qualify for Medicaid. REF: Page 1201 TOP: Long-term care

11. The rehabilitation nurse stresses that the primary difference between rehabilitation of children and rehabilitation of adults is the child's: a. level of disability. b. body part involved. c. degree of disability. d. developmental potential.

ANS: D The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child. REF: Page 1212 TOP: Rehabilitation

14. The nurse assures a 50-year-old patient recovering from a stroke that because she is going to a long-term care facility for a short stay: a. her regular hospitalization insurance will pay for the care. b. she will still have daily physician visits. c. she will need to contract outside physical therapy services. d. she will probably be discharged within 6 months.

ANS: D A short-stay resident in a long-term care facility for rehabilitation will have residential physical therapy services and will usually be discharged within 6 months. REF: Page 1199 TOP: Long-term care

27. The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. An example of an intervention that would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury is: a. encouraging large fluid intake. b. seeking spiritual support from a higher being. c. using the spouse as a support system. d. positioning to maintain alignment.

ANS: D Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability. REF: Page 1211 TOP: Rehabilitation

16. The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering an episode of: a. paresis. b. heterotopic ossification. c. postural hypotension. d. autonomic dysreflexia.

ANS: D Autonomic dysreflexia is caused by a reflex action of the autonomic nervous system. REF: Page 1217 TOP: Rehabilitation

12. The nurse recognizes that the acquisition of adaptive skills and behaviors by an individual who has been disabled since birth is referred to as: a. training. b. education. c. development. d. habilitation.

ANS: D Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills to relearn and are habilitated rather than rehabilitated. REF: Pages 1212-1213 TOP: Habilitation

21. The nurse helps the family understand that once hospice service is initiated, the focus of care changes from rehabilitation and restoration to that of: a. maintaining the patient at the optimal level. b. assisting with funeral planning. c. relieving the family of care. d. maintaining comfort as death approaches.

ANS: D Hospice care is focused on the provision of comfort to the person who is approaching death. REF: Page 1196 TOP: Hospice

33. The rehabilitation nurse references the nursing diagnosis of impaired cognition for a 40-year-old patient who is brain injured and who: a. frequently becomes violent. b. becomes easily fatigued. c. is depressed. d. cannot add three numbers in his head.

ANS: D Impaired cognitive barriers experienced during rehabilitation include problems in thinking, impaired concentration, and impaired information processing. REF: Page 1218 TOP: Rehabilitation

16. The nurse recognizes that there is a time limit for the legal administration of medications, which is: a. 30 minutes. b. 1 hour. c. 90 minutes. d. 2 hours.

ANS: D In long-term care, there is a 2-hour window for legal administration of medications, 1 hour before and 1 hour after the official administration time. REF: Page 1200 TOP: Long-term care Step: Planning

24. When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, the initial intervention is to: a. locate the cause of irritation. b. assess the blood pressure. c. cover the patient with several blankets. d. raise the head of the bed to a high Fowler's position.

ANS: D Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension. REF: Page 1217 TOP: Rehabilitation

23. The nurse assesses a patient's ability to perform self-care activities as well as more complex social and household activities. The result of this assessment provides the patient's: a. physical status. b. emotional status. c. health status. d. functional status.

ANS: D The functional status is related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). REF: Page 1202 TOP: Long-term care

3. The home health nurse helps an older adult couple plan changes in their home that will facilitate care in their home as they age. The nurse recognizes that what percentage of people over 65 live at home? a. 42% b. 48% c. 55% d. 67%

ANS: D The majority (67%) of people over the age of 65 live in a home or family setting. REF: Page 1194 TOP: Long-term care

2. The nurse recognizes that the rehabilitation process involves the efforts of various disciplines whose focus is to build on a person's: a. losses. b. long-term plans. c. drives. d. abilities.

ANS: D The underlying philosophy of rehabilitation is to focus on abilities. REF: Page 1209 TOP: Rehabilitation