Brunner and Suddarth Medical Surgical Nursing 12e by Suzanne C. Smeltzer RNC EdD FAAN

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Brunner and Suddarth Medical Surgical Nursing 12e by Suzanne C. Smeltzer RNC EdD FAAN

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Import Settings:
Base Settings: Brownstone Default
Information Field: Chapter
Information Field: Client Needs
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Highest Answer Letter: E
Multiple Keywords in Same Paragraph: No

Chapter: Chapter 11: Principles and Practices of Rehabilitation

Multiple Choice

1. Rehabilitation nursing deals with many and a variety of problems. When caring for a male patient with urinary incontinence, what intervention would the nurse avoid with this patient?
A) Intermittent self-catheterization
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 192, Assessment and Functional Ability

Feedback: 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 voidings 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.

2. You are the nurse caring for a patient with a pressure ulcer. The nurse on the shift before you has done patient teaching about pressure ulcers and what the patient can do to help heal the pressure ulcer. You assess that the patient has understood the teaching by observing what?
A) Patient performs range-of-motion exercises
B) Patient avoids pressure on the healing site
C) Patient elevates body parts susceptible to edema
D) Patient demonstrates improved level of consciousness

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Page and Header: 185, Assessment and Functional Ability

Feedback: The major goals 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.

3. An elderly female patient who is bedridden is admitted to the unit because of a large pressure ulcer. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. What stage would document this ulcer?
A) I
B) II
C) III
D) IV

Ans: D
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Page and Header: 190, Assessment and Functional Ability

Feedback: 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.

4. Part of the care given to rehabilitation patients is teaching them different ways to exercise their limbs, no matter what the patient is rehabbing for. You are the nurse assisting a stroke patient to exercise. You are coaching the patient to contract and relax her muscles while keeping the extremity in a fixed position. Which type of exercise is the patient completing?
A) Passive
B) Isometric
C) Resistive
D) Abduction

Ans: B
Chapter: 11
Client Needs: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 6
Page and Header: 178, Assessment and Functional Ability

Feedback: Isometric exercises are those in which there are 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.

5. The definition of rehabilitation is a team of professionals working together with the patient and the family. Which member of the rehabilitation team is the one who determines the final outcome of the process?
A) Nurse
B) Patient
C) Family
D) Doctor

Ans: B
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: 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.

6. The Americans with Disabilities Act (ADA), passed in 1990, is civil rights legislation designed to do what?
A) Provide access to the community to those with disabilities
B) Guarantee a job to those with disabilities
C) Provide an above-average income for those who are disabled
D) Make sure those who are disabled are well cared for

Ans: A
Chapter: 11
Client Needs: A-2
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Page and Header: 168, Americans with Disabilities Act

Feedback: In 1990, the U.S. Congress passed the Americans With Disabilities Act (ADA) (PL 101-336), which is civil rights legislation designed to provide people with disabilities access to job opportunities and to the community. It was not designed to guarantee a job, provide an above-average income, or make sure the person who is disabled is well cared for.

7. A nurse is giving a talk to a local community group about those who are disabled in the community. The group is interested in what trends are impacting the care of people who are disabled in the community. What would the nurse be sure to mention in her talk?
A) Extended rehabilitation care
B) Independent living
C) Acute-care center treatment
D) State institutions that provide care for life

Ans: B
Chapter: 11
Client Needs: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 9
Page and Header: 197, Promoting Home and Community-Based Care

Feedback: 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 talk about extended rehabilitation care, acute-care center treatment, or state institutions.

8. A patient is recovering from a stroke. The nurse notes that the patient is unwilling to attempt any self-care. What should the nurse include as an initial goal?
A) The patient will demonstrate independent self-care.
B) The patients family will manage the patients care.
C) The nurse will delegate the patients care to a nursing assistant.
D) The patient will participate in a social program.

Ans: A
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Page and Header: 167, Introduction

Feedback: 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.

9. You are caring for a 35-year-old male who has just been diagnosed with paralysis due to a sky diving accident that injured the spinal cord. How can you anticipate that the patient will react emotionally?
A) Go through all stages of grief in a week so he can adapt
B) Progress sequentially through five stages of the grief process
C) Need humor therapy
D) Respond to grief in an individualistic manner

Ans: D
Chapter: 11
Client Needs: D-3
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Caring
Objective: 3
Page and Header: 168, Patients Reactions to Disability

Feedback: The most frequently reported chronic illness and disability-triggered reactions include shock, which is a short-lived reaction experienced at the onset of a traumatic and sudden injury or the onset of a life-threatening or chronic and debilitating disease; anxiety, which is a panic-like state as the nature and magnitude of the event is processed; denial, which is a defense mechanism used to ward off anxiety and other intense emotions; depression, which reflects the realization of the permanence and magnitude of the chronic illness or disability; anger and hostility that are both self-directed and externalized; and adjustment, which is exemplified by self-acceptance as a person with a chronic illness or disability and marked by reintegration into the community. Finally, chronic illness and disability-associated coping strategies are those psychological strategies that are used to decrease, modify, or diffuse the impact of stressful life events. Humor is a coping strategy that some people use, but people going through life-altering events do not need humor therapy at this point.

10. An elderly female diagnosed with osteoarthritis has been admitted to your unit. The patient has difficulty ambulating because of chronic pain. What intervention may the nurse use to help with the patients mobility?
A) Motivate the patient to walk in the afternoon
B) Determine if self-care devices are needed
C) Administer an analgesic as ordered to increase mobility
D) Have another person with osteoarthritis visit the patient

Ans: C
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Page and Header: 174, Assessment and Functional Ability

Feedback: At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (eg, 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. The nurse should plan for ambulation with the patient and administer the analgesic in advance of the ambulation to allow sufficient time for the analgesic to take action. Motivating the patent or having another person with the same diagnosis visit are not interventions that will help with mobility. Determining if self-care devices are needed is a collaborative assessment; it is not an intervention.

11. Bedridden patients are assessed every shift for evidence of impaired skin integrity due to shear and friction. When making this assessment, the nurse should plan to assess the patients what?
A) Elbows
B) Soles of the feet
C) Heels
D) Knees

Ans: C
Chapter: 11
Client Needs: D-3
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Page and Header: 184, Assessment and Functional Ability

Feedback: The coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction. The other options are incorrect because they would not show evidence of shear and friction.

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. When the ED nurse calls report to the floor, she tells the floor nurse to assess the patient for protein deficiency. What laboratory finding would the floor nurse assess for protein deficiency?
A) Hemoglobin
B) White blood cells
C) Albumin
D) TSH

Ans: C
Chapter: 11
Client Needs: D-3
Cognitive Level: Analysis
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 7
Page and Header: 184, Assessment and Functional Ability

Feedback: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than 3 g/mL are indicative of hypoalbuminemia. Altered hemoglobin levels, changes in white blood cell counts, and TSH levels are not indicators of protein deficiency.

13. A patient who is paralyzed has been diagnosed with reflex incontinence. The nurse caring for the patient should include which preventive measure in the teaching plan with this patient?
A) Regular perineal care to prevent skin breakdown
B) Kegel exercises to strengthen the pelvic floor
C) Small, frequent meals
D) Limited fluid intake to prevent incontinence

Ans: A
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 192, Assessment and Functional Ability

Feedback: 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. Small, frequent meals would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients ability to sense the need to void.

14. A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes. What is the best instruction the nurse can give the patient?
A) Keep a record of when the incontinence occurs
B) Perform clean intermittent catheterization
C) Perform Kegel exercises four to six times per day
D) Wear a protective undergarment as incontinence is part of aging

Ans: C
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Teaching/Learning
Objective: 8
Page and Header: 192, Assessment and Functional Ability

Feedback: 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.

15. While assessing your patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and the patients reluctance to move. What nursing diagnosis do these signs and symptoms indicate?
A) Health-seeking behavior
B) Impaired physical mobility
C) Disturbed sensory perception
D) Deficient knowledge

Ans: B
Chapter: 11
Client Needs: D-3
Cognitive Level: Analysis
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Page and Header: 174, Assessment and Functional Ability

Feedback: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. Health-seeking behavior is a state in which a patient in stable health actively seeks ways to alter personal health habits or the environment in order to move toward optimal health. Disturbed sensory perceptions are changes in the characteristics of incoming stimuli. Deficient knowledge exists when the patient requires further teaching.

16. A stroke patient is now in rehabilitation. What does the nurse know is a major goal of the rehabilitative process?
A) To provide 24-hour care for the patient
B) To restore the patients ability to function independently
C) To allow for a longer hospital stay
D) To adjust treatment based on available staff

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Page and Header: 167, Introduction

Feedback: The goal of rehabilitation is to restore the patients ability to function independently or at a pre-illness or pre-injury level of functioning as quickly as possible. Options A, B, and C are incorrect answers because they are not the goals of rehabilitation.

17. A 52-year-old married man with two adolescent children is beginning rehabilitation following a major traffic accident. You are the nurse planning the patients care. Who should you recognize that the patients condition will affect?
A) Only himself
B) Only his wife and children
C) Him and his entire family
D) No one, if he has a complete recovery

Ans: C
Chapter: 11
Client Needs: C
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 1
Page and Header: 168, Patients Reactions to Disability

Feedback: Patients and families who suddenly experience a physically disabling event or the onset of a chronic illness face several psychosocial adjustments, even if the patient recovers completely. Options A, B, and D are incorrect because the whole family is affected.

18. You are planning rehabilitation activities for a newly admitted patient. The physician has specifically requested rehabilitation in instrumental activities of daily living. What would you know would be considered an instrumental activity of daily living (IADL)?
A) Dressing
B) Bathing
C) Feeding
D) Meal preparation

Ans: D
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Page and Header: 167, Introduction

Feedback: 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.

19. A 93-year-old male stroke patient is exhibiting urinary incontinence. As the nurse, you know that various factors can alter elimination patterns in elderly patients. What is an example of these factors?
A) Decreased residual volume
B) Increased muscle tone
C) Increased bladder capacity
D) Decreased muscle tone

Ans: D
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 191, Assessment and Functional Ability

Feedback: 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. This makes options A, B, and C incorrect.

20. You are the nurse caring for an elderly patient who has been on a bowel training program due to weakness caused by a stroke. The patient is now exhibiting normal bowel patterns. You know that it is important to avoid what once a bowel routine has been well established?
A) A bedpan
B) A padded commode
C) Massage of the abdomen
D) A bedside toilet

Ans: A
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 193, Assessment and Functional Ability

Feedback: 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. These facts make options B, C, and D incorrect.

21. You are a nurse working on a rehabilitation team. You know that a variety of disciplines are represented on the rehab team and that this team of professionals needs to work together with what?
A) Patients and their families
B) Acute-care families and patients
C) Community leaders
D) Long-term care facilities

Ans: A
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: Rehabilitation is a creative, dynamic process that requires a team of professionals working together with patients and families. Option B is incorrect because the rehabilitation team does not work with acute-care patients and families, option C is incorrect because the rehab team does not work with community leaders, and option D is incorrect because rehab teams do not work with long-term care facilities.

22. As a member of the rehabilitation team, the nurses role depends on what?
A) The other members of the team
B) The circumstances of the patient
C) The desires of the family
D) The education level of the nurse

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: Nurses assume an equal or, depending on the circumstances of the patient, a more critical role than other members of the health care team in the rehabilitation process. Options A, C, and D are incorrect because the nurses role on the rehabilitation team does not depend on other members of the team, the familys desires, or the nurses education level.

23. The rehabilitation team works towards maximizing the patients independence. As members of the team, what do nurses do?
A) Encourage families to become paraprofessionals in rehabilitation
B) Make the patient the center of the team
C) Recognize the importance of informal caregivers
D) Make patients and families to work together

Ans: C
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: In working toward maximizing independence, nurses affirm the patient as an active participant and recognize the importance of informal caregivers in the rehabilitation process. Option A is incorrect because nurses do not encourage families to become paraprofessionals in rehabilitation; option B is incorrect because the patient is the center of the team, the nurse does not make the patient the center; option D is incorrect because nurses do not make patients and families work together.

Multiple Selection

24. You are the nurse caring for a 35-year-old female who has just been diagnosed as a paraplegic after a diving accident. What emotions would you expect this patient to exhibit in the early stages of her rehabilitation? (Mark all that apply.)
A) Acceptance
B) Denial
C) Bargaining
D) Hostility
E) Depression

Ans: B, D, E
Chapter: 11
Client Needs: C
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Caring
Objective: 3
Page and Header: 168, Patients Reactions to Disability
Feedback: The most frequently reported chronic illness and disability-triggered reactions include shock, which is a short-lived reaction experienced at the onset of a traumatic and sudden injury or the onset of a life-threatening or chronic and debilitating disease; anxiety, which is a panic-like state as the nature and magnitude of the event is processed; denial, which is a defense mechanism used to ward off anxiety and other intense emotions; depression, which reflects the realization of the permanence and magnitude of the chronic illness or disability; anger and hostility that are both self-directed and externalized; and adjustment, which is exemplified by self-acceptance as a person with a chronic illness or disability and marked by reintegration into the community. Neither option A nor option C will not be exhibited this early in the rehabilitation process.

Multiple Choice

25. The nurse working in rehabilitation knows that there are factors that are common to both disability and chronic illness. What is one of those factors?
A) A certain prognosis
B) A positive impact on family and friends
C) Limited medical treatment
D) Interference with life roles

Ans: D
Chapter: 11
Client Needs: D-4
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 3
Page and Header: 168, Patients Reactions to Disability

Feedback: Certain factors common to both disability and chronic illness may include some functional limitation, interference with daily activities and life roles, an uncertain prognosis, prolonged medical treatment and rehabilitation, psychosocial stress associated with the trauma or disease process, a negative impact on family and friends, and negative economic implications. Therefore, options A, B, and C are incorrect.

26. You are the nurse making the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who had a stroke but who had lived independently until this event. What goal would you know is appropriate for this patient?
A) Maintenance of joint mobility
B) Refer to social services
C) Ambulate three times every day
D) Perform passive range of motion twice daily

Ans: A
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Page and Header: 174, Assessment and Functional Ability

Feedback: The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. Options B, C, and D are incorrect because they are not goals; they are nursing interventions.

27. You are the rehabilitation nurse caring for a 25-year-old patient post motor vehicle accident victim. What do you do during each patient contact?
A) Complete a physical assessment
B) Assist the patient into proper positioning
C) Plan nursing interventions
D) Assist the patient to ambulate

Ans: B
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Page and Header: 174, Assessment and Functional Ability

Feedback: During each patient contact, the nurse evaluates the patients position and assists the patient to achieve and maintain proper positioning and alignment. Option A is incorrect because a nurse does not complete a physical assessment during each patient contact. Options C and D are incorrect because a nurse does not plan nursing interventions or assist the patient to ambulate each time the nurse has contact with the patient.

28. What is the most important reason for the nurse to begin a program for activities of daily living (ADL) as soon as the patient is admitted to a rehabilitation facility?
A) The ability to perform ADLs may be the key to dependence.
B) The ability to perform ADLs is essential to living in a group home.
C) The ability to perform ADLs may be the key to reentry into the community.
D) The ability to perform ADLs is necessary to function in an assisted-living situation.

Ans: C
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Page and Header: 171, Assessment and Functional Ability

Feedback: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. Option A is incorrect because ADLs are frequently the key to independence, not dependence; options B and D are incorrect because they are not the most important reason to begin an ADL program as soon as the patient is admitted to rehabilitation.

29. The nurse must observe and assess the patients ability to perform ADLs to determine the level of independence in self-care and the need for nursing intervention. What else should the nurse be aware of?
A) What the activity of bathing requires
B) How to assist the patient to brush her teeth
C) How to get the patient to express satisfaction with her life
D) The familys involvement in the patients ADLs

Ans: D
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Page and Header: 171, Assessment and Functional Ability

Feedback: The nurse should also be aware of the patients medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the familys involvement in the patients ADLs. Options A and B are incorrect because these are not what the nurse needs to be aware of when assessing the patients ability to perform ADLs. Option C is incorrect because this is not an assessment function; it is a nursing intervention.

30. What is an important nursing intervention when working with a patient who has self-care deficits in activities of daily living?
A) To provide an optimal learning environment with minimal distractions
B) To have the patient express satisfaction with the extent of independence achieved in home care activities
C) To know the requirements of assisted-living centers
D) To allow no distractions during teaching/learning events

Ans: A
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Page and Header: 171, Assessment and Functional Ability

Feedback: The nurses role is to provide an optimal learning environment that minimizes distractions. Options B, C, and D are incorrect because they are not nursing interventions.

31. You are admitting a patient into your rehabilitation unit with a diagnosis of impaired sensation secondary to falling from a tree stand. You know that this patient may need what to accomplish self-care?
A) Family assistance
B) Assistive devices
C) A personal aide
D) An assisted-living environment

Ans: B
Chapter: 11
Client Needs: D-4
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Page and Header: 172, Assessment and Functional Ability

Feedback: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. Options A and C are incorrect because you should not need the assistance of other people to accomplish self-care activities. Option D is incorrect because you should not need an assisted-living environment to accomplish self-care.

32. The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What is the foundation of preparation for ambulation?
A) Desire
B) Strength
C) Exercise
D) Ability

Ans: C
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Page and Header: 179, Assessment and Functional Ability

Feedback: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulationwhether with brace, walker, cane, or crutchesthe patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation. Options A, B, and D are incorrect because none of those is the foundation of preparation for ambulation.

33. When preparing a patient for ambulation, the nurse and patient work closely with the physical therapist. After sitting and standing balance is achieved, what is the patient able to use?
A) Cane
B) Crutches
C) Walker
D) Parallel bars

Ans: D
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 6
Page and Header: 180, Assessment and Functional Ability

Feedback: After sitting and standing balance is achieved, the patient is able to use parallel bars. Options A, B, and C are incorrect because the patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.

Multiple Selection

34. The rehabilitation nurse works closely with her patient who has a new orthosis. What is the nurses responsibility to this patient? (Mark all that apply.)
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 fitting of the orthosis
D) Assist the patient in learning how to move the affected body part correctly
E) Arrange for the physical therapist to work with the patient

Ans: A, B, D
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Caring
Objective: 7
Page and Header: 183, Assessment and Functional Ability
Feedback: In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely or if it is adjusted improperly. Options C and D are incorrect because they are not part of the nurses responsibility to the patient.

Multiple Choice

35. When a patient is transferred home or to a long-term care facility, what maintains his continuity of care?
A) The nursing staff
B) A referral system
C) Their plan of care
D) Keeping the same rehabilitation team

Ans: B
Chapter: 11
Client Needs: D-4
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 9
Page and Header: 195, Promoting Home and Community-Based Care

Feedback: A referral system maintains continuity of care when the patient is transferred to the home or to a long-term care facility. Option A is incorrect because there is no nursing staff at home nor is there the same nursing staff when the patient is transferred to a different facility. Option C is incorrect because the plan of care from one facility does not follow the patient to another facility and there is no plan of care at home. Option D is incorrect because the rehabilitation team is different from one facility to another, and there may not be a rehabilitation team when the patient is transferred home.

36. A home care nurse makes her initial visit to a patient being discharged from a rehabilitation facility. This initial visit is to assess what the patient can do and to see what he will need when discharged home. What does this help ensure for the patient?
A) Social relationships
B) Family assistance
C) Continuity of care
D) A positive self-image

Ans: C
Chapter: 11
Client Needs: B
Cognitive Level: Knowledge
Difficulty: Moderate
Integrated Process: Caring
Objective: 9
Page and Header: 195, Promoting Home and Community-Based Care

Feedback: A home care nurse may visit the patient in the hospital, interview the patient and the family, and review the ADL sheet to learn which activities the patient can perform. This helps ensure that continuity of care is provided and that the patient does not regress but instead maintains the independence gained while in the hospital or rehabilitation setting. Options A, B, and D are incorrect because this initial visit does not ensure social relationships, family assistance, or a positive self-image.

Multiple Selection

37. Nursing, by its very definition, fulfills many functions when caring for patients in the rehabilitation setting. What are these functions? (Mark all that apply.)
A) Identifying members of the rehabilitation team
B) Setting dietary limitations
C) Managing skin care
D) Fostering self-care
E) Coping with the disability

Ans: C, D, E
Chapter: 11
Client Needs: D-4
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Page and Header: 169, The Rehabilitation Team
Feedback: Coping with the disability, fostering self-care, identifying mobility limitations, and managing skin care and bowel and bladder training are areas that frequently require nursing care. Options A and B are incorrect as nurses do not identify members of the rehabilitation team nor do they set dietary limitations; dieticians do that.

Multiple Choice

38. Patients at risk for the development of pressure ulcers sometimes need what?
A) Special equipment
B) Family support
C) Home health aides
D) Bathing assistance

Ans: A
Chapter: 11
Client Needs: A-2
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 7
Page and Header: 188, Assessment and Functional Ability

Feedback: At times, special equipment and beds may be needed to help relieve the pressure on the skin. This is particularly important for patients who cannot get out of bed and who have risk factors for pressure ulcer development. Options B, C, and D are incorrect because none of these has to do with altering risk factors for pressure ulcers.

39. Physiologic risk factors for elimination problems are explored in what nursing function?
A) Physical assessment
B) Health history
C) Genetic history
D) Initial assessment

Ans: B
Chapter: 11
Client Needs: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 191, Assessment and Functional Ability

Feedback: The health history is used to explore bladder and bowel function, symptoms associated with dysfunction, physiologic risk factors for elimination problems, perception of micturition (urination or voiding) and defecation cues, and functional toileting abilities. Options A, C, and D are incorrect because elimination problems are not explored in these nursing functions.

40. You are the nurse caring for a patient who is immobile due to a hunting accident. You know to assess for the development of pressure ulcers on this patient. Why would you know to do this?
A) You know that this patient will be immobile only until the cast comes off.
B) You know that this patient has a lot of support in maintaining proper alignment.
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
Chapter: 11
Client Needs: D-3
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 7
Page and Header: 184, Assessment and Functional Ability

Feedback: The development of pressure ulcers is directly related to the duration of immobility: if pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. Option A is incorrect because a cast can remain in place for months. Option B is incorrect because a patient with support for maintaining proper alignment has less chance of developing a pressure ulcer than a patient without this support. Option D is incorrect because 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.

41. A nurse is caring for a patient during rehabilitation following a skiing accident. Within what role is the nurse functioning when she coordinates the patients total rehabilitative plan of care?
A) Patient educator
B) Caregiver
C) Case manager
D) Patient advocate

Ans: C
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: When the nurse coordinates the patients total rehabilitative plan of care, the nurse is functioning as a case manager. The nurse must coordinate services provided by all of the team members. Options A, B, and D are incorrect because these roles do not coordinate the patients total rehabilitative plan of care.

42. You are the nurse assessing a patient with limited mobility after a stroke. What would you do to assess the patient for contractures?
A) Orientation
B) Muscle flexibility
C) Muscle strength
D) Range of motion

Ans: D
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Page and Header: 173, Assessment and Functional Ability

Feedback: Each joint of the body has a normal range of motion. To assess a patient for contractures, the nurse should assess whether the patient can complete the full range of motion. Options A, B, and C are incorrect because assessing orientation, muscle flexibility, or muscle strength are not what a nurse assesses for contractures.

43. You are caring for a patient who is hospitalized following a total hip replacement. What would the nurse do to prevent inward rotation of the patients hip when the patient is in a partial lateral position?
A) Use an abduction pillow
B) Align the head with the spine and support it with a pillow
C) Support the back with a small pillow
D) Place trochanter rolls under the greater trochanter

Ans: A
Chapter: 11
Client Needs: D-3
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Page and Header: 178, Assessment and Functional Ability

Feedback: Raised, padded commode seats may also be warranted for patients who must avoid flexing the hips greater than 90 degrees when transferring to a toilet. It is important that the nurse teach the patient hip precautions (ie, no adduction past the midline, no flexion greater than 90 degrees, and no internal rotation); abduction pillows can be used to keep the hip in correct alignment if precautions are warranted.

44. Your patient has a stage III pressure ulcer. What would be the best meal choice for this patient?
A) Cheeseburger and fries
B) Skim milk, oatmeal, and whole wheat toast
C) Steak, baked potato, spinach and strawberry salad
D) Eggs, bacon, hash browns, and an apple

Ans: C
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Page and Header: 190, Assessment and Functional Ability

Feedback: The patient should be encouraged to eat foods high in protein; carbohydrates; and vitamins A, B, and C. Options A, B, and D do not have the appropriate nutrients needed by this patient.

45. You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would be the best to prevent pressure ulcers?
A) Turn and reposition the patient a minimum of every eight hours
B) Vigorously massage lotion into bony prominences
C) Post a turning schedule at the patients bedside
D) Slide, rather than lift, the patient when turning

Ans: C
Chapter: 11
Client Needs: A-3
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Page and Header: 188, Assessment and Functional Ability

Feedback: A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every one to two hours, not every eight hours, for patients 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 patient, the nurse should lift, rather than slide, the patient to avoid shearing.

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