Nokea
A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
- A. Use analgesic before and after activity, even if you are not experiencing pain.
- B. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
- C. Use physical therapy before and after activity.
- D. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Correct Answer: B
Rationale: Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must instruct the client to report symptoms such as shortness of breath, chest pain, or fatigue, which indicate that the heart is not receiving adequate oxygen during activity. Using analgesics prophylactically is not necessary unless prescribed. Physical therapy is a structured program, not something used before and after activity. Rescheduling therapy due to knee pain may delay recovery, and pain should be managed appropriately instead.
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A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
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 is caring for clients as a member of the rehabilitation team. Which activities should the nurse perform? (Select all that apply.)
- A. Maintain the safety of adaptive devices by monitoring their function and making repairs.
- B. Coordinate rehabilitation team activities to ensure implementation of the plan of care.
- C. Assist clients to identify support services and resources for the continuation of services.
- D. Counsel clients and family members on strategies to cope with disability.
- E. Support the clients' choices by acting as an advocate for the client and family.
Correct Answer: B,E
Rationale: The rehabilitation nurse coordinates team activities to ensure the plan of care is implemented and advocates for the client and family. Maintaining adaptive devices is the role of a biomedical technician, assisting with support services is the social worker's role, andcounseling on coping strategies is handled by a clinical psychologist.
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- A. Insert an indwelling urinary catheter.
- B. Stroke the medial aspect of the thigh.
- C. Use the Credé maneuver every 3 hours.
- D. Apply a Texas catheter with a leg bag.
Correct Answer: C
Rationale: The Credé maneuver, which involves applying manual pressure to the bladder, can facilitate voiding in clients with a flaccid bladder due to a spinal cord injury at T3. Indwelling catheters increase the risk of urinary tract infections and are generally avoided. Stroking the medial thigh is used for upper motor neuron issues, not flaccid bladders. A Texas catheter is unsuitable as the client may be unaware of a full bladder and unable to control voiding.
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.