Nokea
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
Correct Answer: C
Rationale: 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.
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A home care nurse performs Chomsky visit to a patient who is soon 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. Realistic expectations
Correct Answer: C
Rationale: 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. This initial visit does not ensure social relationships, family assistance, or realistic expectations.
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.
Correct Answer: C
Rationale: 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.
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
Correct Answer: A
Rationale: Of spinal cord injuries,50 % are related to substance abuse, and approximately50\%$ 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.
You are the nurse providing care for a patient who has limited mobility after a stroke. What would you do to assess the patient for contractures?
- 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.
Correct Answer: D
Rationale: 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. Assessing DTRs, muscle size, or joint pain do not reveal the presence or absence of contractures.
You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position?
- A. Use of an abduction pillow between the patients legs
- B. Alignment of the head with the spine using a pillow
- C. Support of the lower back with a small pillow
- D. Placement of trochanter rolls under the greater trochanter
Correct Answer: A
Rationale: Abduction pillows can be used to keep the hip in correct alignment if precautions are warranted following hip replacement. Trochanter rolls and back pillows do not achieve this goal.