Question 1

The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid?

Accepted Answer

Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.

Question 2

You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what?

Accepted Answer

The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.

Question 3

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer?

Accepted Answer

Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

Question 4

A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing?

Accepted Answer

Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.

Question 5

An interdisciplinary team has been working collaboratively to improve the health outcomes of a young
Adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process?

Accepted Answer

The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.

Question 6

A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should highlight what salient risk factor for traumatic brain injury?

Accepted Answer

Of spinal cord injuries, $50 \%$ are related to substance abuse, and approximately $50 \%$ of all patients with traumatic brain injury were intoxicated at the time of injury. This association exceeds the significance of sports participation, anger mismanagement, or lack of community resources.

Question 7

A nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care?

Accepted Answer

There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not describe extended rehabilitation care, acute-care center treatment, or state institutions because these are not increasing in importance.

Question 8

The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patients electronic health record reveals that the patient usually defers her selfcare to family members or members of the care team. What should the nurse include as an initial goal when planning this patients subsequent care?

Accepted Answer

An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patients care, the patients care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.

Question 9

You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-theknee amputations. How can you anticipate that the patient will respond to this news?

Accepted Answer

Loss of limb is a profoundly emotional experience, which the patient will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the patients grief. The patient may or may not benefit from psychotherapy.

Question 10

An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility?

Accepted Answer

At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to push through the pain.

Question 11

The nurse is providing care for a 90 -year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area?

Accepted Answer

Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.

Question 12

An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?

Accepted Answer

Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than $3 \mathrm{~g} / \mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.

Question 13

A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?

Accepted Answer

Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no
sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.

Question 14

A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?

Accepted Answer

For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.

Question 15

While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?

Accepted Answer

Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.

Question 16

A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process?

Accepted Answer

The goal of rehabilitation is to restore the patients ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizing time in acute care are not central goals of rehabilitation.

Question 17

A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. You are the nurse planning the patients care. Who will the patients condition affect?

Accepted Answer

Patients and families who suddenly experience a physically disabling event or the onset of a chronic illness are the ones who face several psychosocial adjustments, even if the patient recovers completely.

Question 18

You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following?

Accepted Answer

Instrumental activities of daily living (IADLs) include grocery shopping, meal preparation, housekeeping, transportation, and managing finances. Activities of daily living (ADLs) include bathing dressing, feeding, and toileting.

Question 19

A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors?

Accepted Answer

Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.

Question 20

You are the nurse caring for an elderly patient who has been on a bowel training program due to the neurologic effects of a stroke. In the past several days, the patient has begun exhibiting normal bowel patterns. Once a bowel routine has been well established, you should avoid which of the following?

Accepted Answer

Use of bedpans should be avoided once a bowel routine has been established. An acceptable alternative to a private bathroom is a padded commode or bedside toilet. Massaging the abdomen from right to left facilitates movement of feces in the lower tract.

Quiz 10: Principles and Practices of Rehabilitation