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A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process?
- A. To provide 24-hour, collaborative care for the patient
- B. To restore the patients ability to function independently
- C. To minimize the patients time spent in acute care settings
- D. To promote rapport between caregivers and the patient
Correct Answer: B
Rationale: The goal of rehabilitation is to restore the patients ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizing time in acute care are not central goals of rehabilitation.
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A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?
- A. Keep a record of when the incontinence occurs.
- B. Perform clean intermittent self-catheterization.
- C. Perform Kegel exercises four to six times per day.
- D. Wear a protective undergarment to address this age-related change.
Correct Answer: C
Rationale: For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.
You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers?
- A. Turn and reposition the patient a minimum of every 8 hours.
- B. Vigorously massage lotion into bony prominences.
- C. Post a turning schedule at the patients bedside and ensure staff adherence.
- D. Slide, rather than lift, the patient when turning.
Correct Answer: C
Rationale: A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.
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.
The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area?
- A. The patients elbows
- B. The soles of the patients feet
- C. The patients heels
- D. The patients knees
Correct Answer: C
Rationale: Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.
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.