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Ch 10 - Test bank
Medical Surgical 1 (MURS_3144_01_UG_MAIN_MEDICAL-SURGICALNURSING1)
Southeastern University
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Chapter 10: Principles and Practices of Rehabilitation
The nurse is providing care for an older adult man whose diagnosis of dementia has recently leurinary incontinence. When planning this patients care, what intervention should the nurse avoid?d to A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads Ans: B Feedback: Indwelling catheters are avoided if at all possible because of the high incidence of urininfections with their use. Intermittent self-catheterization is an appropriate alternative for managingary tract reflex incontinence, urinary retention, and overflow incontinence related to an overdistendedExternal catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male bladder. patients with reflex or total incontinence. Incontinence pads should be used as a last resoonly manage, rather than solve, the incontinence. rt because they
You are the nurse caring for a female patient who developed a pressure ulcer as a resumobility. The nurse on the shift before you has provided patient teaching about pressure ulcers andlt of decreased healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site. Ans: B Feedback: The major goals of pressure ulcer treatment may include relief of pressure, improsensory perception, improved tissue perfusion, improved nutritional status, minimized fricved mobility, improvedtion and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The othnot demonstrate the achievement of the goal of the patient teaching. er options do
An elderly female patient who is bedridden is admitted to the unit because of a pressurelonger be treated in a community setting. During your assessment of the patient, you find that the ulcer that can noulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV Ans: D Feedback: Stage III and IV pressure ulcers are characterized by extensive tissue damage listed for stage I, these advanced draining, necrotic pressure ulcers mu In addition to thest be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlbone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer,ying muscle and necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with presStage II involves a break in the skin that may drain. sure.
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currentlyinpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her receiving extremity in a fixed position. Which type of exercise is the patient performing? A) Passive B) Isometric C) Resistive D) Abduction Ans: B Feedback: Isometric exercises are those in which there is alternating contraction and relkeeping the part in a fixed position. This exercise is performed by the patient. Passive exeraxation of a muscle whilecises are carried out by the therapist or the nurse without assistance from the patient. Resistcarried out by the patient working against resistance produced by either manual or mechanicaive exercises arel means. Abduction is movement of a part away from the midline of the body.
An interdisciplinary team has been working collaboratively to improve the health outcomes of a young
C) Acute-care center treatment D) State institutions that provide care for life Ans: B Feedback: There is a growing trend toward independent living for patients who are severely disabled, eitor in groups. The goal is integration into the community. The nurse would be sure to mention this facther alone 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.
- The nurse is caring for an older adult patient who is receiving rehabilitation followinstroke. A review of the patients electronic health record reveals that the patient usually defers her self-g an ischemic care to family members or members of the care team. What should the nurse include as when planning this patients subsequent care? an initial goal
A) The patient will demonstrate independent self-care. B) The patients family will collaboratively manage the patients care. C) The nurse will delegate the patients care to a nursing assistant. D) The patient will participate in a life skills program. Ans: A Feedback: An appropriate patient goal will focus on the patient demonstrating independent self-carerehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and. The independence. The other options are incorrect because an appropriate goal would not be for the famimanage the patients care, the patients care would not be delegated to a nursing assistant, and ly to participating in a social program is not an appropriate initial goal. 9. You are caring for a 35-year-old man whose severe workplace injuries necessitate knee amputations. How can you anticipate that the patient will respond to this news?bilateral below-the-
A) The patient will go through the stages of grief over the next week to 10 days. B) The patient will progress sequentially through five stages of the grief process. C) The patient will require psychotherapy to process his grief.
D) The patient will experience grief in an individualized manner. Ans: D Feedback: Loss of limb is a profoundly emotional experience, which the patient will experience in a sumanner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is notbjective possible to accurately predict the sequence or timing of the patients grief. The patienbenefit from psychotherapy. t may or may not
An elderly woman diagnosed with osteoarthritis has been referred for care. The patieambulating because of chronic pain. When creating a nursing care plan, what intervention may the nt has difficultynurse use to best promote the patients mobility? A) Motivate the patient to walk in the afternoon rather than the morning. B) Encourage the patient to push through the pain in order to gain further mobility. C) Administer an analgesic as ordered to facilitate the patients mobility. D) Have another person with osteoarthritis visit the patient. Ans: C Feedback: At times, mobility is restricted because of pain, paralysis, loss of muscle streimmobilizing device (e., cast, brace), or prescribed limits to promote healing. If mobilngth, systemic disease, anity is restricted because of pain, providing pain management through the administration of an analgesic will increpatients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent orase the having another person with the same diagnosis visit is not an intervention that will help withThe patient should not be encouraged to push through the pain. mobility.
The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility defiin the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planningcits result relevant assessments, the nurse should prioritize inspection of what area? A) The patients elbows B) The soles of the patients feet C) The patients heels D) The patients knees
sensory awareness of the need to void. Total incontinence occurs in patients with a psychologicaimpairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegell exercises. Intravenous fluids would make no difference in reflex incontinence. Limitedwould make no impact on a patients inability to sense the need to void. fluid intake
- A female patient, 47 years old, visits the clinic because she has been experiencing strwhen she sneezes or exercises vigorously. What is the best instruction the nurse can give thess incontinencee patient?
A) Keep a record of when the incontinence occurs. B) Perform clean intermittent self-catheterization. C) Perform Kegel exercises four to six times per day. D) Wear a protective undergarment to address this age-related change. Ans: C Feedback: For cognitively intact women who experience stress incontinence, the nurse should instruct perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Kethe patient toeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrecbecause they are of no value in treating stress incontinence. Women with stress incontinence do not needt answers clean intermittent catheterization. Protective undergarments hide the effecthey do not resolve the problem. ts of urinary incontinence but
While assessing a newly admitted patient you note the following: impaired coordination, decmuscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these reasedsigns and symptoms most clearly suggest? A) Ineffective health maintenance B) Impaired physical mobility C) Disturbed sensory perception: Kinesthetic D) Ineffective role performance Ans: B Feedback: Impaired physical mobility is a limitation of physical movement that is identifiedfound in this patient. The other listed diagnoses are not directly suggested by the noted assessm by the characteristicsent findings.
A patient has completed the acute treatment phase of care following a stroke and the begin rehabilitation. What should the nurse identify as the major goal of the rehabilitativpatient will nowe process?
A) To provide 24-hour, collaborative care for the patient B) To restore the patients ability to function independently C) To minimize the patients time spent in acute care settings D) To promote rapport between caregivers and the patient Ans: B Feedback: The goal of rehabilitation is to restore the patients ability to function independently or atpreinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizi a preillness orng time in acute care are not central goals of rehabilitation. 17. A 52-year-old married man with two adolescent children is beginning rehabilitation follvehicle accident. You are the nurse planning the patients care. Who will the patients conditowing a motorion affect?
A) Himself B) His wife and any children that still live at home C) Him and his entire family D) No one, provided he has a complete recovery Ans: C Feedback: Patients and families who suddenly experience a physically disabling event or the onset of a illness are the ones who face several psychosocial adjustments, even if the patient recovers completely
- You are planning rehabilitation activities for a patient who is working toward dischargcommunity. During a care conference, the team has identified a need to focus on the patientse back into the instrumental activities of daily living (IADLs). When planning the patients subsequent focus particularly on which of the following? care, you should
A) Dressing
Ans: A Feedback: Use of bedpans should be avoided once a bowel routine has been established. An acceptable alternatto a private bathroom is a padded commode or bedside toilet. Massaging the abdomen from right to lefivet facilitates movement of feces in the lower tract. 21. As a member of the rehabilitation team, the nurse is conscious of the need to perform thcollaboration with the other members of the team. Which of the following variables has the nursing role ine greatest bearing on the nurses choice of actions and interventions during rehabilitative care? A) The skills of the other members of the team B) The circumstances of the patient C) The desires of the patients family D) The nurses education and experience level Ans: B Feedback: Nurses assume an equal or, depending on the circumstances of the patient, a more criticalmembers of the health care team in the rehabilitation process. The nurses role on the rehabilitation team role than other does not depend primarily on other members of the team, the familys desires, or the nurses edlevel. ucation
- The rehabilitation team has reaffirmed the need to maximize the independence of a rehabilitation. When working toward this goal, what action should the nurse prioritize?patient in
A) Encourage families to become paraprofessionals in rehabilitation. B) Delegate care planning to the patient and family. C) Recognize the importance of informal caregivers. D) Make patients and families to work together. Ans: C Feedback:
In working toward maximizing independence, nurses affirm the patient as an active particrecognize the importance of informal caregivers in the rehabilitation process. Nurses do not encourageipant and families to become paraprofessionals in rehabilitation. The patient and family arplanning is not their responsibility. Nurses do not make patients and families work together central, but care
- You are the nurse creating the care plan for a patient newly admitted to your rehabilitapatient is an 82-year-old patient who has had a stroke but who lived independently until this event. Whattion unit. The is a goal that you should include in this patients nursing care plan? A) Maintain joint mobility. B) Refer to social services. C) Ambulate three times every day. D) Perform passive range of motion twice daily. Ans: A Feedback: The major goals may include absence of contracture and deformity, maintenance of muscle joint mobility, independent mobility, increased activity tolerance, and prevention of further strength anddisability. The other listed actions are interventions, not goals.
- You are the rehabilitation nurse caring for a 25-year-old patient who suffered extensivmotorcycle accident. During each patient contact, what action should you perform most frequene injuries in atly?
A) Complete a physical assessment. B) Evaluate the patients positioning. C) Plan nursing interventions. D) Assist the patient to ambulate. Ans: B Feedback: During each patient contact, the nurse evaluates the patients position and assists the and maintain proper positioning and alignment. The nurse does not complete a physical assessmenpatient to achievet during each patient contact. Similarly, the nurse does not plan nursing interventions or assistto ambulate each time the nurse has contact with the patient. the patient
- A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most
A) To provide an optimal learning environment with minimal distractions B) To describe the evidence base for any chosen interventions C) To help the patient become aware of the requirements of assisted-living centers D) To ensure that the patient is able to perform self-care without any aid from caregivers Ans: A Feedback: The nurses role is to provide an optimal learning environment that minimizes distractithe evidence base is not a priority, though nursing actions should indeed be evidence-based. Assisted-ons. Describing living facilities are not relevant to most patients. Absolute independence in ADLs isgoal for every patient. not an appropriate
You are admitting a patient into your rehabilitation unit after an industrial accidendiagnoses include disturbed sensory perception and you assess that he has decreased strength ant. The patients nursingd dexterity. You know that this patient may need what to accomplish self-care? A) Advice from his family B) Appropriate assistive devices C) A personal health care aide D) An assisted-living environment Ans: B Feedback: Patients with impaired mobility, sensation, strength, or dexterity may need to use assisaccomplish self-care. An assisted-living environment is less common than the use of assistive devices devices to Family involvement is imperative, but this may or may not take the form of advice. A healthcanot needed by most patients. re aide is
The nurse is working with a rehabilitation patient who has a deficit in mobility followiaccident. The nurse knows that preparation for ambulation is extremely important. What nursng a skiinging action will best provide the foundation of preparation for ambulation? A) Stimulating the patients desire to ambulate B) Assessing the patients understanding of ambulation
C) Helping the patient perform frequent exercise D) Setting realistic expectations Ans: C Feedback: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulatwith brace, walker, cane, or crutchesthe patient must strengthen the muscles required. Therefore,ionwhether exercise is the foundation of preparation. 30. A patient is undergoing rehabilitation following a stroke that left him with severe modeficits. The patient has been unable to ambulate since his accident, but has recently actor and sensoryhieved the goals of sitting and standing balance. What is the patient now able to use? A) A cane B) Crutches C) A two-wheeled walker D) Parallel bars Ans: D Feedback: After sitting and standing balance is achieved, the patient is able to use parallel barable to use the parallel bars before he can safely use devices like a cane, crutches, or a walker. The patient must be
- The rehabilitation nurse is working closely with a patient who has a new orthosis followiinjury. What are the nurses responsibilities to this patient? Select all that apply. ng a knee
A) Help the patient learn to apply and remove the orthosis. B) Teach the patient how to care for the skin that comes in contact with the orthosis. C) Assist in the initial fitting of the orthosis. D) Assist the patient in learning how to move the affected body part correctly. E) Collaborate with the physical therapist to set goals for care.
A home care nurse may visit the patient in the hospital, interview the patient and the famthe ADL sheet to learn which activities the patient can perform. This helps ensure that continuity of careily, and review is provided and that the patient does not regress, but instead maintains the independence gained whthe hospital or rehabilitation setting. This initial visit does not ensure social relationships, family ile in assistance, or realistic expectations. 34. A nurse has been asked to become involved in the care of an adult patient in his fifties who hasexperienced a new onset of urinary incontinence. During what aspect of the assessment should the nurse explore physiologic risk factors for elimination problems? A) Physical assessment B) Health history C) Genetic history D) Initial assessment Ans: B Feedback: The health history is used to explore bladder and bowel function, symptoms associated with dysfunctphysiologic risk factors for elimination problems, perception of micturition (urination or voiding) andion, defecation cues, and functional toileting abilities. Elimination problems are not explolisted aspects of assessment. red in the other
- You are the nurse caring for a patient who has paraplegia following a hunting accident. You know toassess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action? A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility. Ans: C Feedback: The development of pressure ulcers is directly related to the duration of immobility: continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer If pressureresults. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration
of the immobility is what matters. Paraplegia does not result in a decreased levelthere is no reason to believe that the patient does not want to prevent pressure ulcers. of consciousness and 36. A nurse is caring for a patient undergoing rehabilitation following a snowboarding accident. Wiinterdisciplinary team, the nurse has been given the responsibility for coordinating the patients totalthin the rehabilitative plan of care. What nursing role is this nurse performing? A) Patient educator B) Caregiver C) Case manager D) Patient advocate Ans: C Feedback: When the nurse coordinates the patients total rehabilitative plan of care, the nurse iscase manager. The nurse must coordinate services provided by all of the team members. Th functioning as ae other answers are incorrect. 37. You are the nurse providing care for a patient who has limited mobility after a stroke. Whdo to assess the patient for contractures? at would you
A) Assess the patients deep tendon reflexes (DTRs). B) Assess the patients muscle size. C) Assess the patient for joint pain. D) Assess the patients range of motion. Ans: D Feedback: Each joint of the body has a normal range of motion. To assess a patient for contractures, the nursshould assess whether the patient can complete the full range of motion. Assessing DTRs, muscle size,e or joint pain do not reveal the presence or absence of contractures. 38. You are creating a nursing care plan for a patient who is hospitalized following right totareplacement. What nursing action should you specify to prevent inward rotation of the patients hipl hip when the patient is in a partial lateral position?
Ans: C Feedback: A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, helprevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who arep in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoidvigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.
- The nurse is providing care for an older adult man whose diagnosis of dementia has recently leurinary incontinence. When planning this patients care, what intervention should the nurse avoid?d to
A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads Ans: B Feedback: Indwelling catheters are avoided if at all possible because of the high incidence of urininfections with their use. Intermittent self-catheterization is an appropriate alternative for managingary tract reflex incontinence, urinary retention, and overflow incontinence related to an overdistendedExternal catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male bladder. patients with reflex or total incontinence. Incontinence pads should be used as a last resoonly manage, rather than solve, the incontinence. rt because they
- You are the nurse caring for a female patient who developed a pressure ulcer as a resumobility. The nurse on the shift before you has provided patient teaching about pressure ulcers andlt of decreased healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site.
Ans: B
Feedback: The major goals of pressure ulcer treatment may include relief of pressure, improsensory perception, improved tissue perfusion, improved nutritional status, minimized fricved mobility, improvedtion and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The othnot demonstrate the achievement of the goal of the patient teaching. er options do
An elderly female patient who is bedridden is admitted to the unit because of a pressurelonger be treated in a community setting. During your assessment of the patient, you find that the ulcer that can noulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV Ans: D Feedback: Stage III and IV pressure ulcers are characterized by extensive tissue damage listed for stage I, these advanced draining, necrotic pressure ulcers mu In addition to thest be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlbone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer,ying muscle and necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with presStage II involves a break in the skin that may drain. sure.
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currentlyinpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her receiving extremity in a fixed position. Which type of exercise is the patient performing? A) Passive B) Isometric C) Resistive D) Abduction Ans: B
Ch 10 - Test bank
Course: Medical Surgical 1 (MURS_3144_01_UG_MAIN_MEDICAL-SURGICALNURSING1)
University: Southeastern University
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