NUR126 Chp 10: Principles and Practices of Rehabilitation

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? Potassium, 3.0 Hemoglobin, 10.5 Hematocrit, 43.5 Albumin, 1.5 g/dL

Albumen: 1.5 g/dL Patients with albumen levels of less than 3 g/dL are associated with hypoalbuminemic tissue edema and increased risk of impaired skin integrity related to pressure ulcers. Anemia can also increase the risk for pressure ulcers; however, a hemoglobin of 10.5 and a hematocrit of 43.5 are within the normal range. Although potassium of 3.0 is low, this does not put the patient at increased risk for impaired skin integrity

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs? Placing hand rolls on the balls of each foot Attaching braces or splints to each foot and leg Putting slippers on the client's feet Crossing the client's ankles every 2 hours

Attaching braces or splints to each foot and leg Attaching braces or splints to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment

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? Calcium Potassium Protein Phosphorous

Protein Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased? Urge incontinence Stress incontinence Reflex (neurogenic) incontinence Functional incontinence

Stress incontinence Stress incontinence may occur with coughing or sneezing, which increase intra-abdominal pressure. Urge incontinence is involuntary elimination of urine associated with a strong perceived need to void. Neurogenic incontinence is associated with a spinal cord lesion. Functional incontinence refers to incontinence in clients with intact urinary physiology and who experience mobility impairment, environmental barriers, or cognitive problems

A type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is active-assistive. isometric. passive. resistive.

isometric Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Active-assistive exercises are carried out by the patient with the assistance of the therapist or the nurse.

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 Specialty mattress Gel flotation pad Water bed

Ring or donut The nurse shouldn't use rings or donuts with any client because this equipment restricts circulation. Specialty mattresses evenly distribute pressure. Gel pads redistribute the client's weight, and water beds distribute pressure over the entire surface

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 Physician Physical therapist Nurse

Patient

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 3-point 4-point Swing-to

Swing-through

Rotation of the forearm so that the palm of the hand is down is termed supination eversion pronation inversion

pronation Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that turns the sole of the foot inward. Supination is rotation of the forearm so that the palm of the hand is up. Eversion is the return movement from flexion.

To prevent foot drop, the client is positioned in a sitting position with legs hanging off the side of the bed. in a semi-sitting position in bed. in a side-lying position. to keep the feet at right angles to the leg.

to keep the feet at right angles to the leg. In order to prevent foot drop, the feet must be supported. When the patient is supine in bed, padded splints or protective boots are used. Semi-Fowler's positioning is used to decrease the pressure of abdominal contents on the diaphragm. Side-lying positions do not provide support to prevent foot drop.

The nurse preceptor is critiquing a new nurse's plan of care for a client with urinary incontinence. The preceptor suggests a review of nursing interventions for urinary incontinence when which instruction appears on the plan of care? "Encourage Kegel exercises." "Restrict client's fluids." "Initiate a toileting schedule." "Encourage cranberry juice."

"Restrict client's fluids." not advised

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? Grooming Cooking Bathing Dressing

Cooking Instrumental activities of daily living (IADLs) include: cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, and handling emergencies. Bathing, grooming, dressing, & eating are activities of daily living (ADLs)

Which therapeutic exercise is done by the nurse without assistance from the client? Isometric Resistive Passive Active

Passive Passive therapeutic exercise is carried out by the therapist or the nurse without assistance from the client. Active therapeutic exercises are accomplished by the client without assistance. Resistive exercise is carried out by the client working against resistance produced by either manual or mechanical means. Isometric exercise is described as alternately contracting and relaxing a muscle while keeping the part in a fixed position.

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? A loss of sexual functioning correlates with a loss of sexual feeling. Most care tasks required after discharge focus on the physical care. Fatigue primarily results from physical demands. Priority setting is helpful in dealing with the impact of the disability.

Priority setting is helpful in dealing with the impact of the disability. For clients with disabilities, the nurse would emphasize the use of coping strategies and teach the patient how to cope with the disability through priority setting.

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? Vitamin C Water Protein Zinc sulfate

Protein Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.

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 III Stage IV Stage I Stage II

Stage II A stage II pressure ulcer is considered a partial-thickness wound. A stage I pressure ulcer is an area of erythema that does not blanch with pressure. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends to the underlying muscle and bone

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

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

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 the affected leg. advance both legs. advance both crutches. advance the unaffected leg.

advance both crutches The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step

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." "Eat plenty of fruits and vegetables throughout the day." "Do not delay the urge to move your bowels when it occurs." "Try to increase your activity level a bit more."

"Keep your fluid intake to fewer than 2 liters per day." NOT appropriate To promote bowel elimination, the nurse should suggest a daily fluid intake of 2 to 3 liters per day unless contraindicated and encourage the patient to respond to the urge to defecate.

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 Around lunchtime Before bed Upon arising

After breakfast Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation.

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 pillows under the lower legs. a hip-abductor pillow. a trochanter roll extending from the crest of the ilium to the midthigh. a footboard.

a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Pillows under the legs will not prevent the hips from rotating externally. A hip-abductor pillow is used for the patient after total hip replacement surgery. A footboard will not prevent the hips from rotating externally

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? Greater trochanter Lateral malleolus Ischial tuberosity Scapula

ischial tuberosity For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleous would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

pressure ulcer stages

stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. stage III ulcer extends into the subcutaneous tissue. stage II ulcer exhibits a break in the skin through the epidermis or dermis. stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort

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: functional incontinence. stress incontinence. reflex incontinence. total incontinence.

stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime.

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. Cooking Bathing Toileting Cleaning Eating

Bathing Toileting Eating ADLs refer to those activities related to personal care, such as bathing, using the toilet, and eating. Cleaning and cooking are independent ADLs--activities that are important for independent living.

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? Bananas Applesauce Bran cereal Pop-Tart

Bran cereal To prevent constipation, the patient should eat a diet with an adequate intake of high-fiber foods; therefore, the nurse should encourage the patient to select the bran cereal.

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and secondary to diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position? Recumbent Fowler's Prone Lateral

Recumbent Although a patient should be repositioned laterally, prone, and dorsally in sequence, the recumbent position is preferred to the semi-Fowler's position because this position provides an increased body surface area of support.

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? Emphasize areas of strengths. Avoid seeking help from others. Stop any activity once fatigue occurs. Group any heavy work to be done at the same time.

Emphasize areas of strengths. to assist a patient in coping with his or her disability, the nurse would encourage the patient to emphasize strengths, stop activities before fatigue occurs, distribute heavy work throughout the day or week, and recruit assistance from others, delegating when necessary.

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? Keeps the head erect while combing the hair Lifts one leg by raising it off the ground Uses the handrail on one side to go down the stairs Holds onto the furniture when walking in the house

Holds onto the furniture when walking in the house Holding onto the furniture or other objects in the room when ambulating suggests difficulty with movement.

In which stage is a pressure ulcer considered a partial-thickness wound? Stage IV Stage I Stage II Stage III

Stage II A stage II ulcer is a partial-thickness wound, break in the skin with edema and some drainage.

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 I pressure ulcer Stage III pressure ulcer Stage II pressure ulcer Stage IV pressure ulcer

Stage II pressure ulcer A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

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

Stage IV stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. stage III ulcer extends into the subcutaneous tissue. stage II ulcer exhibits a break in the skin through the epidermis or dermis. stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort

Half of all spinal cord injuries are related to motorcycle accidents. genetic predisposition. work-related injuries. substance abuse.

Substance abuse Of spinal cord injuries, 50% are related to substance abuse & approximately 50% of all patients with traumatic brain injury were intoxicated at the time. Motorcycle accidents, genetic predisposition, and work-related injuries do not account for 50% of spinal cord injuries.

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? Range-of-motion exercises Trochanter roll Pillow between the legs Protective boots

Trochanter roll A trochanter roll extending from the crest of the ilium to the mid-thigh prevents external rotation of the hip. Range-of-motion exercises are used to maintain muscle strength and joint mobility. Protective boots are used to prevent footdrop. Using a pillow between the legs would help support the body in the correct alignment

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 Dorsiflexion Adduction Pronation

Opposition Opposition involves touching the thumb to each fingertip on the same hand. Adduction would involve moving the arm away from the midline of the body. Pronation involves rotating the forearm so that the palm of the hand is down. Dorsiflexion involves movement that flexes or bends the hand back toward the body.

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown? Leg rest of the wheelchair Sitting in the wheelchair for long periods of time Specialty boots Absence of sensation in the lower extremities and immobility

Specialty boots The area of skin breakdown was most likely caused by the specialty boot — ordered to reduce pressure in the heels — rubbing against the skin. Although the wheelchair leg rest is located near the wound site, the wound described is likely to be caused by pressure, not a laceration caused by contact with the leg rest. Immobility and decreased sensation places the client at risk for skin breakdown, but these factors aren't the direct cause of this wound. A paraplegic is capable of sitting in a wheelchair for extended periods because he can shift his weight throughout the day.

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.) a. Have a fluid intake between 2 and 4 L/day. b. Set a daily defecation time that is within 15 minutes of the same time every day. c. Have an adequate intake of fiber containing foods. d. Take a laxative daily. e. Take a retention enema daily.

a. Have a fluid intake between 2 and 4 L/day. b. Set a daily defecation time that is within 15 minutes of the same time every day. c. Have an adequate intake of fiber containing foods. Regularity, timing, nutrition (including increased fiber intake), and fluids (2 to 4 L daily), exercise, and correct positioning promote predictable defecation (National Institute for Health and Clinical Excellence, 2010). A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily. Enemas and laxatives are only needed if the patient is constipated and then only as needed, not daily

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? Stress incontinence Toilet incontinence Reflex (neurogenic) incontinence Functional incontinence

reflex (neurogenic) incontinence Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased. Toilet incontinence occurs in clients who cannot control excreta because of physiologic or psychological impairment. Functional incontinence occurs in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and can not reach and use the toilet before soiling themselves