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TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

183

Chapter10:PrinciplesandPracticesofRehabilitation  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?

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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.

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?

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,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.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

3.

184

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?

A)

I

B)

II

C)

III

D)

IV

Ans:

D 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.

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?

A)

Passive

B)

Isometric

C)

Resistive

D)

Abduction

Ans:

B Feedback: 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.

5.

Aninterdisciplinaryteamhasbeenworkingcollaborativelytoimprovethehealthoutcomesofayoung

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

185

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? A)

Most-responsiblenurse

B)

Patient

C)

Patientsfamily

D)

Primarycarephysician

Ans:

B 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.

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?

A)

Substanceabuse

B)

Sportsparticipation

C)

Angermismanagement

D)

Lackofcommunityresources

Ans:

A Feedback: 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.

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?

A)

Extendedrehabilitationcare

B)

Independentliving

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

C)

Acute-carecentertreatment

D)

Stateinstitutionsthatprovidecareforlife

Ans:

B

186

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describeextendedrehabilitationcare, acute-carecentertreatment,orstateinstitutionsbecausethesearenotincreasinginimportance. 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?

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-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manwhosesevereworkplaceinjuriesnecessitatebilateralbelow-thekneeamputations.Howcanyouanticipatethatthepatientwillrespondtothisnews?

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.

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

D)

Thepatientwillexperiencegriefinanindividualizedmanner.

Ans:

D

187

Feedback: 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. 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? 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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.

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? A)

Thepatientselbows

B)

Thesolesofthepatientsfeet

C)

Thepatientsheels

D)

Thepatientsknees

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

Ans:

188

C Feedback: 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.

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? A)

Hemoglobin

B)

Bilirubin

C)

Albumin

D)

Cortisol

Ans:

C 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,cortisollevels,andbilirubinlevelsarenot indicatorsofproteindeficiency.

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? A)

Regularperinealcaretopreventskinbreakdown

B)

Kegelexercisestostrengthenthepelvicfloor

C)

AdministrationofhypotonicIVfluid

D)

Limitedfluidintaketopreventincontinence

Ans:

A Feedback: Reflexincontinenceisassociatedwithaspinalcordlesionthatinterruptscerebralcontrol,resultinginno

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

189

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. 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? 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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.

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? 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identifiedbythecharacteristics foundinthispatient.Theotherlisteddiagnosesarenotdirectlysuggestedbythenotedassessment findings.

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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? 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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.

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? 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chronic illnessaretheoneswhofaceseveralpsychosocialadjustments,evenifthepatientrecoverscompletely.

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? A)

Dressing

TestBank-Brunner&Suddarth'sTextbookofMedical-SurgicalNursing14e(Hinkle2017)

B)

Bathing

C)

Feeding

D)

Mealpreparation

Ans:

D

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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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? A)

Decreasedresidualvolume

B)

Urethralstenosis

C)

Increasedbladdercapacity

D)

Decreasedmuscletone

Ans:

D 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.Theothernoted phenomenaareatypical.

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? A)

Useofabedpan

B)

Useofapaddedorraisedcommode

C)

Massageofthepatientsabdomen

D)

Useofabedsidetoilet

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192

A 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.

21. Asamemberoftherehabilitationteam,thenurseisconsciousoftheneedtoperformthenursingrolein collaborationwiththeothermembersoftheteam.Whichofthefollowingvariableshasthe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criticalrolethanother memb...