Nokea
A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
- A. Liaising with the patients insurer to describe the patients successes.
- B. Teaching the patient about the pathophysiology of her functional deficits.
- C. Eliciting ways to get the patient to express a positive attitude.
- D. Appraising the familys involvement in the patients ADLs.
Correct Answer: D
Rationale: 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. It is not normally necessary to teach the patient about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.
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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.
Correct Answer: A
Rationale: 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.
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 nurse is caring for a patient undergoing rehabilitation following a snowboarding accident. Within the interdisciplinary team, the nurse has been given the responsibility for coordinating the patients total rehabilitative plan of care. What nursing role is this nurse performing?
- A. Patient educator
- B. Caregiver
- C. Case manager
- D. Patient advocate
Correct Answer: C
Rationale: 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. The other answers are incorrect.
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
- C. Acute-care center treatment
- D. State institutions that provide care for life
Correct Answer: B
Rationale: 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.
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 nursing 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
Correct Answer: C
Rationale: 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.