Chapter 10

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

To keep the feet at right angles to the leg

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.

Bathing Toileting Eating

Which type of scale is used to systematically assess and quantify a client's risk for pressure ulcer?

Braden scale

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

Bran cereal

A nurse is 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

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

Stress incontinence

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

reflex (neurogenic) incontinence.

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?

Holds onto the furniture when walking in the house

Serum albumin is an indicator of which type of deficiency?

Protein

While assessing a patient's sacral area, the nurse observes a stage I pressure ulcer. Which of the following images best depicts what the nurse has observed?

erythema that does not blanch with pressure

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

opposition.

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate?

"Keep your fluid intake to fewer than 2 liters per day."

A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. What statement made by the family indicates that more teaching is needed?

"We elevate the head of the bed to comfort level throughout the day."

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

2.5 g/mL

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

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?

After breakfast

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk?

Albumin, 1.5 g/dL

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

Cooking

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

A nurse is caring for a client who is documented to have orthostatic hypotension. The nurse anticipates finding which symptom upon assessment?

Dizziness

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

Functional Independence Measure

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next?

Have the patient lie back down.

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?

Incontinence and right-sided hemiparesis

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which nutritional deficiency may delay wound healing?

Lack of vitamin C

A 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

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

Passive

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?

Patient

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.

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?

Pronation

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

The nurse is caring for a client with a spinal cord injury who has no awareness of the need to void. The nurse should document that the client has which type of incontinence?

Reflex (neurogenic) incontinence

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

What position should be avoided when positioning a patient in bed in order to decrease the incidence of musculoskeletal complications?

Semi-Fowler's

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

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

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

Stage II

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

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

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

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

A 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.

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is

isometric.

Rotation of the forearm so that the palm of the hand is down is termed

pronation.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

stress incontinence.

The nurse is performing range-of-motion exercises. Which of the following best depicts dorsiflexion of the foot?

the nurse moves the foot up and down toward the leg

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?

Ulnar deviation