Chapter 10: Principles and Practices of Rehabilitation

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

"Rehabilitation focuses on the person's abilities." Explanation: Rehabilitation focuses on abilities, not disabilities. It begins with the initial contact with the patient. The goal is to restore the patient's ability to function independently or at a pre-illness or pre-injury level of functioning as quickly as possible. If this is not possible, the aims are to maximize independence and prevent secondary disability as well as to promote a quality of life acceptable to the patient. It includes the use of adaptive and assistive devices to promote the greatest level of independence possible.

The nurse is performing a skin assessment on a bedbound client who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than

1 hour. Explanation: The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

Abduction Explanation: Movement away from the body or midline is called abduction. Movement toward the midline is called adduction. Rotation is the act of turning of a part around its axis. Supination is the act of turning the palm anteriorly.

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 Explanation: 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

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures. Explanation: Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Placing an indwelling catheter and administering vitamin B12 would not be effective measures in preventing continuous moisture.

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 Explanation: Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that runs 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.

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?

Pushes the popliteal area against the mattress while raising the heel Explanation: The client demonstrates quadriceps-setting exercises by attempting to push the popliteal area against the mattress and at the same time raising the heel. With gluteal setting exercises, the client contracts the buttocks together for a count of five and then relaxes them for a count of five. With push-up exercises, the client raises the body by pushing the hands against the chair seat or mattress while he is in a sitting position. For pull-up exercises, the client lifts the body off the mattress while holding onto a trapeze while in bed or raises the arms above the head then lowers them while holding weights.

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 Explanation: Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g per dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Serum glucose is used to assess for diabetes. Prothrombin time is used to assess clotting time and monitor therapeutic levels of anticoagulation medications. Sedimentation rate is used to detect inflammation in the body.

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

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

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. Explanation: 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 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 Explanation: Serum albumin is a sensitive indicator of protein deficiency. Levels below 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.

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 Explanation: Attaching braces or splints to each foot and leg prevents foot drop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent foot drop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.

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 Explanation: 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?

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

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 Explanation: 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, and dressing are activities of daily living (ADLs).

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. Explanation: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

Edema Anemia Diaphoresis Explanation: Risk factors for pressure ulcer development include prolonged pressure on the tissue, sensory deficit or loss, edema, urinary or fecal incontinence, malnutrition, anemia, hypoproteinemia, and excessively moist skin.

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

Explanation: Indicators of orthostatic hypotension include a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.

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?

Explanation: The patient is demonstrating the swing-through gait, in which both crutches are advanced and then both feet are swung forward, landing in front of the crutches. The 4-point gait involves advancing the right crutch, then the left foot, then the left crutch, and then the right foot. The 3-point gait involves advancing the left foot and both crutches, then advancing the right foot, then advancing the left foot and both crutches, and finally advancing the right foot. The swing-to gait involves advancing both crutches and then lifting both feet, swinging them forward and landing them next to the crutches.

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

Functional Independence Measure Explanation: One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (trade marked- FIM), a minimum data set consisting of 18 items. The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.

The nurse is completing an initial assessment on an elderly client with impaired mobility. When asked about urinary patterns, the client states, "I can never get to the bathroom in time." The nurse documents this as which type of incontinence?

Functional incontinence Explanation: The nurse should document this as functional incontinence, defined as incontinence when the urinary system is intact and the client experiences mobility impairment, environmental barriers, or cognitive problems and cannot reach and/or use the toilet before soiling themselves. Urge incontinence is due to loss of bladder muscle , reflex incontinence is due to possible nerve damage, and stress incontinence is due to an activity such as coughing or sneezing.

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. Explanation: The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in position.

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 Explanation: 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 malleolus would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

The nurse is creating a bowel evacuation program for a paraplegic client. When should the nurse plan to administer a suppository?

Just before breakfast Explanation: The best time to plan for bowel evacuation when establishing a bowel regime is 30 minutes after breakfast to take advantage of natural reflexes. Suppositories to promote evacuation should be administered 30 minutes before the desired evacuation time. Therefore, the nurse in this example should plan for the suppository to be administered just before the client's breakfast.

Which nutritional deficiency may delay wound healing?

Lack of vitamin C Explanation: Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing. Vitamin E isn't necessary for wound healing.

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

Lubricating the skin with a non-irritating lotion Explanation: To help reduce the risk of pressure ulcers, the nurse should lubricate the skin with a bland lotion to keep it soft and pliable. Reddened areas should not be massaged because this could damage the capillaries and deep tissues. Clients should shift their weight every 15 to 20 minutes. The semi-reclining position should be avoided because it increases the shearing forces over the sacral area.

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture Explanation: Although skin color, tissue perfusion, and drainage are important assessment areas to address, the Braden scale uses the following categories to predict pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

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. Explanation: A patient's approach to self-care may be affected by altered or impaired mobility and influenced by family or cultural expectations. The inability to perform self-care as carried out previously may lead to ineffective coping behaviors such as social isolation, dependency on caregivers, or depression. The nurse must motivate the patient to learn and accept responsibility for self-care. It helps to encourage an "I'd rather do it myself" attitude. The nurse must also help the patient identify the safe limits of independent activity; knowing when to ask for assistance is particularly important. The nurse educates, guides, and supports the patient who is learning or relearning how to perform self-care activities while maintaining a focus on patient strengths and optimal level of function.

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 Explanation: 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.

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

Passive Explanation: 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.

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 Explanation: Although the nurse, physician, and physical therapist play important roles in the rehabilitation process, the patient is a key member of the rehabilitation team, the focus of the team's efforts, and the one who determines the final outcomes of the process.

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. Explanation: 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 loss of sexual functioning does not necessarily correspond to a loss of sexual feeling. Rather, the physical and emotional aspects of sexuality, despite the physical loss of function, continue to be important for people with disabilities. The fatigue associated with disabilities results from numerous factors, such as the physical and emotional demands, as well as the ineffective coping, unresolved grief, disordered sleep patterns, and depression. Although the most obvious care tasks after discharge involve physical care, other elements of the caregiving role include psychosocial support and a commitment to this supportive role

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 Explanation: 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 working with a physical therapist to create a multidisciplinary plan of care for a client in a rehabilitation unit. The therapist suggests that the client would benefit from the use of light weights during shoulder exercises. The nurse incorporates this into the plan of care as which type of exercise?

Resistive Explanation: The nurse should incorporate exercise that involves the use of light weights, referred to as resistive exercise. In active-assistive exercises the client performs the exercises with assistance from the therapist. In passive exercises, the nurse performs the exercise without assistance from the client. In isometric exercises, the client alternately contracts and relaxes the muscle while keeping the part in a fixed position.

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. Explanation: 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 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 Explanation: 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.

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

Stage III Stage IV Explanation: Stages III and IV pressure ulcers are considered full-thickness wounds. Deep tissue injury is a localized area of discolored, purple, intact skin or blood-filled blister caused by underlying soft tissue damage from pressure or shear. Stage I ulcer is characterized by erythema. Stage II pressure ulcer is a partial-thickness wound.

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

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

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

Stress incontinence Explanation: 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.

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 Explanation: When the client 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. To prevent foot drop, the feet must be supported at right angles to the leg. Side-lying positions do not provide support to prevent foot drop.

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 Explanation: 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 foot drop. Using a pillow between the legs would help support the body in the correct alignment.

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 Explanation: Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches.

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

document the condition of the client's skin. Explanation: The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy.

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

isometric. Explanation: Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position. Resistive exercises are carried out by a client 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 client. Active-assistive exercises are carried out by the client with the assistance of the therapist or nurse.

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 Explanation: When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk assessment encompasses review of existing pressure ulcers as well as potential areas for development of pressure ulcers. Foley catheter output and family history of pressure ulcers are not important when assessing skin integrity.

Half of all spinal cord injuries are related to

substance abuse. Explanation: Of spinal cord injuries, 50% are related to substance abuse, and approximately 50% of all clients 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.