Nokea
A nurse has been asked to become involved in the care of an adult patient in his fifties who has experienced a new onset of urinary incontinence. During what aspect of the assessment should the nurse explore physiologic risk factors for elimination problems?
- A. Physical assessment
- B. Health history
- C. Genetic history
- D. Initial assessment
Correct Answer: B
Rationale: 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. Elimination problems are not explored in the other listed aspects of assessment.
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The rehabilitation team has reaffirmed the need to maximize the independence of a patient in rehabilitation. When working toward this goal, what action should the nurse prioritize?
- A. Encourage families to become paraprofessionals in rehabilitation.
- B. Delegate care planning to the patient and family.
- C. Recognize the importance of informal caregivers.
- D. Make patients and families to work together.
Correct Answer: C
Rationale: In working toward maximizing independence, nurses affirm the patient as an active participant and recognize the importance of informal caregivers in the rehabilitation process. Nurses do not encourage families to become paraprofessionals in rehabilitation. The patient and family are central, but care planning is not their responsibility. Nurses do not make patients and families work together.
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
Correct Answer: A
Rationale: 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.
You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care?
- A. Advice from his family
- B. Appropriate assistive devices
- C. A personal health care aide
- D. An assisted-living environment
Correct Answer: B
Rationale: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.
An interdisciplinary team has been working collaboratively to improve the health outcomes of a young 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
Correct Answer: B
Rationale: 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.
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.