Chapter 10: Principles and Practices of Rehabilitation - Page 169

A patient in rehabilitation has become dependent on family members' assistance with self-care. What can the nurse do to encourage the patient to become independent? (Select all that apply.)

• Motivate the patient to learn and accept responsibilities for self-care. • Help the patient identify safe limits of independent activity. • Educate the patient in how to perform self-care activities.

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effectiveteaching?

"I'll eat plenty of fruits and vegetables."

A family will be providing care at home to an immobilized patient at risk for impaired skin integrity. After teaching the family about reducing the patient's risk for skin breakdown, the nurse determines that the teaching was successful when the family states which of the following?

"We need to make sure that the patient drinks enough fluids."

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 caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms 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 (FIMTM)

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is which of the following?

Isometric

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Nutrition support and orthotics

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

Passive

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

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient?

Protein

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 albumin

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

Stage IV

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

pronation

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

reflex (neurogenic) 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

The nurse assessing a patient on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain on which of the following movements?

Abduction

The nurse is reading the previous shift's documentation of an open area on the patient's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the patient's sacrum will reveal a pressure ulcer in which of the following stages?

Stage II

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 needs to navigate stairs routinely at home