Question 1

The nurse is obtaining an admission history of a client with hip problems.The client asks,"Why are you asking about my bowels and bladder?" What is the nurse's best response?

Accepted Answer

Bowel elimination varies from client to client and must be evaluated on the basis of the client's normal routine.The nurse asks about bowel and bladder to develop a client-centered plan of care.The other answers are correct but are not the best response.Oral analgesics may cause constipation,but they do not interfere with bladder control.Elimination usually is scheduled around rehabilitation activities but should be taken into consideration when a plan of care is developed.The client is in rehabilitation to assist her or his ability to function independently.

Question 2

The nurse is caring for a client with a spinal cord injury at level T3.How will the nurse assist the client with bladder dysfunction?

Accepted Answer

If the spinal cord injury is above T12,the client is unaware of a full bladder and does not void or is incontinent.Therefore,the client would not benefit from a Texas catheter with a leg bag.Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Credé maneuver.Indwelling urinary catheters generally are noted used because of the increased incidence of urinary tract infection.Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems.

Question 3

The nurse is caring for a rehabilitation client.Which activity plan should the nurse implement to best conserve a client's energy without compromising physical or mental health?

Accepted Answer

Some of the best techniques for energy conservation include spacing activities with a rest period in between,and individualizing the scheduling of more energy-intensive activities to the time of day when the client knows or feels that his or her energy levels are higher.

Question 4

The nurse is providing education for a client at risk for urinary tract infection.Which beverage should the nurse encourage the client to drink?

Accepted Answer

Some organisms,such as Escherichia coli,do not grow well in an acidic environment.Fluids that promote an acidic urine include cranberry juice,prune juice,bouillon,tomato juice,and water.

Question 5

The nurse is caring for a bedridden client.Which intervention will the nurse implement to prevent pressure ulcer formation?

Accepted Answer

Assessing serum albumin levels helps determine the client's nutritional status and allows care providers to alter the diet,as needed,to prevent pressure ulcers.All other options are treatment oriented rather than prevention oriented.

Question 6

The nurse is planning care for a client who is beginning a structured cardiac rehabilitation program.Before starting the program,what should the nurse do first?

Accepted Answer

The level of activity that can be accomplished without experiencing shortness of breath needs to be established before activity is begun.This will alleviate fear and anxiety and will prevent the occurrence of cardiac symptoms.Oxygen should be started only if the pulse oximetry reading is below 90%,or if electrocardiographic changes or cardiac symptoms occur,none of which is indicated in this question.Nitroglycerin should be given only if the client has a history of angina.Orthostatic hypotension should be assessed before a client is ambulated,but this assessment does not provide information specific to the client's cardiac rehabilitation program.

Question 7

The nurse is caring for a client who is undergoing rehabilitation.Which nursing intervention would be best to prevent venous stasis and thrombus formation?

Accepted Answer

Range-of-motion exercises involve skeletal muscle contraction of the upper and lower extremities.Muscle contraction promotes venous return,preventing stasis and thrombus formation.Foot support can help prevent contractures and foot drop.Increased calcium is not related to venous stasis and thrombus formation,nor is avoiding sudden position changes.

Question 8

The client who is performing intermittent self-catheterization at home is concerned about the cost of the catheters.What is the nurse's best response?

Accepted Answer

At home,clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections.The nurse would refer the client to the social worker to explore financial concerns.The nurse should not threaten the client,nor should the client be instructed to boil the catheters.

Question 9

The nurse is caring for a client who has long-standing chronic obstructive pulmonary disease (COPD)and is recovering from a stroke.Which intervention is a priority when activity tolerance is assessed during rehabilitation?

Accepted Answer

To see whether a client is tolerating activity,vital signs are measured before,during,and after the activity.If the client is not tolerating activity,heart rate may increase more than 20 beats/min,blood pressure may increase over 20 mm Hg,and vital signs will not return to baseline within 5 minutes after the activity.A cognitive assessment is not necessary before basic activities are performed.A consultation would not provide data on activity tolerance,and monitoring of self-care ability does not directly reflect tolerance as vital signs do.

Question 10

The nurse delegates the unlicensed nursing assistant (UAP)to ambulate an older adult client.What information must the nurse communicate to the UAP when delegating this task?

Accepted Answer

Before the client gets out of bed,have the client sit on the bed with legs dangling on the side.This will enhance safety for the client.The UAP cannot assess the client's pain or teach the client to use a walker.A gait belt should be used for all clients.

Question 11

A paraplegic client is being evaluated for transfer to a rehabilitation unit.The nurse refers the client to which interdisciplinary team member for evaluation of activities of daily living?

Accepted Answer

The occupational therapist is responsible for ADL training,the physical therapist for muscle strength,the vocational therapist for job training,and the recreational therapist for hobbies or pastime activities.

Question 12

The nurse is teaching a client who is a paraplegic about prescribed rehabilitation.The client verbalizes that he doesn't know why he should go.What is the nurse's best response?

Accepted Answer

There are many purposes for participating in rehabilitation programs,including disability prevention,maintenance of functional ability,and restoration of function.Without the special knowledge learned through rehabilitation,the client with a newly acquired disability may never learn the skills needed to prevent long-term problems or conserve energy.

Question 13

The nurse is caring for a client in a rehabilitation center.Which test will best assist the nurse in determining the severity of a client's disability?

Accepted Answer

The FIM attempts to quantify what the person actually does,whatever the diagnosis or impairment.Categories for assessment consist of self-care,sphincter control,mobility,locomotion,communication,and cognition.The functional independence measure is a uniform data set used for outcome data collection in the United States.IADL is a functional assessment tool carried out by numerous members of the interdisciplinary team in the health care setting.The MDS is used to assess nursing home residents in areas of motor ability,sensation,and cognition,as well as overall health status.

Question 14

The rehabilitation nurse is caring for an obese client with new bilateral leg amputations.The nurse is planning to move the client from the bed to the chair.What is the best approach?

Accepted Answer

Use mechanical lifts to minimize staff work-related musculoskeletal injuries.The bear-hug method and the use of several members of the team do not eliminate staff injuries.Physical therapy should be consulted but cannot be depended on for all transfers.Nursing staff must be capable of transferring a client safely.

Question 15

A nurse catheterizes a client immediately after voiding.The residual volume is 50 mL.What will the nurse do next?

Accepted Answer

This finding is normal.Therefore,the nurse should document the finding and continue with the present bladder training program.The goals of a bladder training program are to avoid the use of an indwelling catheter and to keep the residual volume at less than 100 mL.

Question 16

The nurse is caring for a client with decreased mobility.What intervention should the nurse include in the care plan to best help this client decrease the risk of fracture?

Accepted Answer

Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium,contributing to maintenance of bone density and reducing the risk for bone fracture.Although increasing calcium in the diet is a good intervention,this alone will not reduce the client's susceptibility to bone fracture.A foot support and pressure-relieving devices will not help prevent fracture,but may help with mobility and skin integrity.

Question 17

The nurse assesses a client admitted for rehabilitation.The client has generalized weakness and needs assistance with activities of daily living.Which exercise should the nurse implement?

Accepted Answer

Active range of motion is a part of a restorative nursing program.Active range of motion will promote strength,range of motion,and independence with activities of daily living.

Question 18

A client with a past history of angina had a total knee replacement.What will the nurse teach the client before rehabilitation activities are begun?

Accepted Answer

Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need.Nitroglycerin dilates coronary arteries within 5 minutes of use,ensuring that they will be ready to meet the demand during exercise.

Question 19

The nurse is planning care for a client who is newly wheelchair bound owing to a spinal cord injury.What priority intervention should the nurse include in the plan of care to assist the client in transferring from the bed to the wheelchair?

Accepted Answer

With impaired mobility and use of a wheelchair,the client tends to gain weight.During rehabilitation,the client should be on a high-protein diet but not calorie restriction.The increased weight requires greater upper body strength for movement.The nurse should encourage the client to perform exercises that strengthen the upper arms.The nurse should consult physical therapy to assist with these exercises.Occupational therapy would not be involved in movement of the client but would be involved with ADLs.Bowel and bladder retraining may prevent skin breakdown but has nothing to do with the client's ability to transfer to the wheelchair.

Question 20

The nurse is performing passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees.What action by the nurse is best?

Accepted Answer

Moving a joint beyond the point at which the client feels pain or resistance can damage the joint.The nurse should move the joint only to the point of resistance.Splinting the joint will not assist the client's range of motion.The client's joint should not be forced.Applying weights to the extremity will not increase range of motion of the joint but most likely will cause damage.

Quiz 8: Rehabilitation Concepts for Chronic and Disabling Health Problems