Med Surg. Chapter 10

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

Isometric

To prevent footdrop, the patient is positioned

to keep the feet at right angles to the leg.

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

Functional Independence Measure (FIMTM)

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

Which of the following terms means movement away from the midline of the body?

Abduction

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

"All weight should be on the hands."

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."

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

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

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to:

distribute weight away from the involved side.

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description?

"Habilitation focuses on the person's abilities."

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."

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

To help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use which of the following?

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

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splints

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

Braden scale

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding.

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 a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment?

Dizziness

Which nutritional deficiency may delay wound healing?

Lack of vitamin C

A nurse is performing passive range of motion to a client's upper extremeities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

Opposition

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

Opposition

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter?

Overall risk of developing pressure ulcers

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

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.

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

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

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. A stage I ulcer is characterized by an area of erythema that does not blanch with pressure. A stage II ulcer is a partial-thickness wound characterized by a break in the skin with edema and some drainage. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

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

Stage IV

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 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

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 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.

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

Nutrition support and orthotics

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.

• Toileting • Bathing • Eating

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 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