Nokea
A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the patient is admitted to a rehabilitation facility?
- A. The ability to perform ADLs may be the key to dependence.
- B. The ability to perform ADLs is essential to living in a group home.
- C. The ability to perform ADLs may be the key to reentry into the community.
- D. The ability to perform ADLs is necessary to function in an assisted-living situation.
Correct Answer: C
Rationale: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.
You may also like to solve these questions
You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action?
- A. You know that this patient will have a decreased level of consciousness.
- B. You know that this patient may not be motivated to prevent pressure ulcers.
- C. You know that the risk for pressure ulcers is directly related to the duration of immobility.
- D. You know that the risk for pressure ulcers is related to what caused the immobility.
Correct Answer: C
Rationale: The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the patient does not want to prevent pressure ulcers.
A patient is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system? Using this system achieves what goal of the patients care?
- A. Minimizing costs of the patients care
- B. Maintaining continuity of the patients care
- C. Maintain the nursing care plan between diverse sites
- D. Keeping the primary care provider informed
Correct Answer: B
Rationale: A referral system maintains continuity of care when the patient is transferred to the home or to a long-term care facility. The interests of cost and of keeping the primary care provider informed are not primary. The nursing plan is likely to differ between sites.
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
- A. Ineffective health maintenance
- B. Impaired physical mobility
- C. Disturbed sensory perception: Kinesthetic
- D. Ineffective role performance
Correct Answer: B
Rationale: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.
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.
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.