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A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity violence?
- A. Vital signs before, during, and after activity
- B. Body image and self-care abilities
- C. Vital signs use and self-care device devices
- D. Clients electrocardiography readings
Correct Answer: A
Rationale: To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.
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A rehabilitation nurse is caring for an older adult client who states, 'I tire easily.' How should the nurse respond? (Select all that apply.)
- A. Make a schedule for completing major tasks in the morning.
- B. Use a cart to push your belongings instead of carrying them.
- C. Your family should hire someone who can assist you with daily chores.
- D. Plan to gather all of the supplies needed for a chore prior to starting the activity.
- E. Try to break large activities into smaller parts to allow rest periods between activities.
Correct Answer: B,D,E
Rationale: Using a cart reduces energy expenditure compared to carrying items. Gathering supplies before starting a chore minimizes unnecessary steps. Breaking large activities into smaller parts allows rest periods, helping manage fatigue. Scheduling major tasks in the morning is a good strategy but not listed as an option. Hiring assistance is not ideal as it does not promote independence.
A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
- A. Splint the joint and continue passive range of motion to the shoulder only.
- B. A passive range of motion to the right elbow and the right knee back to the right.
- C. Apply weights to the right distal extremity before initiating any joint exercise.
- D. Continue to move the joint only to the point at which resistance is met.
Correct Answer: D
Rationale: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance to prevent injury. Splinting the joint will not assist the client's range of motion and may restrict it further. The option of passive range of motion to the elbow and knee is unclear and not a standard practice. Applying weights to the extremity will not increase range of motion and could cause harm.
A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- A. Place pillows under the client's heels.
- B. Have the client do wheelchair push-ups.
- C. Perform wound care as prescribed.
- D. Massage the client's calves and feet with lotion.
Correct Answer: B
Rationale: Clients who are wheelchair-bound should perform wheelchair push-ups for at least 10 seconds every hour to relieve pressure on weight-bearing areas, reducing the risk of skin breakdown. Pillows under the heels may increase pressure, wound care treats existing ulcers, and massaging the calves in clients with decreased mobility risks embolization.
A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?
- A. Stroking the medial aspect of the thigh.
- B. Valsalva maneuver
- C. Use the Credé maneuver
- D. Apply a Texas catheter with a leg bag.
- E. Frequent toileting
Correct Answer: B
Rationale: The Valsalva maneuver, which involves bearing down to increase intra-abdominal pressure, can help initiate voiding in clients with a flaccid bladder where the voiding reflex is not intact. The Credé maneuver is also appropriate but is listed separately, and the Valsalva maneuver is specifically highlighted as effective in this context. Stroking the thigh is for upper motor neuron issues, a Texas catheter is not suitable, and frequent toileting is used for uninhibited bladders.
A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?
- A. 3,5,1,2,4,6
- B. 3,5,2,4,1,6
- C. 3,5,1,2,4,6
- D. 3,5,4,1,2,6
Correct Answer: C
Rationale: The correct sequence for gait training with a cane for a client with left-sided weakness is: (3) Guide the client to a standing position, (5) Place the cane in the client's right hand (strong side), (1) Position for left and around the client's waist for support, (2) Move the cane and left leg forward at the same time, (4) Move the right leg and step forward, (6) Check balance and repeat the sequence. This ensures safe and effective ambulation.