Nokea
A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use?
- A. A cane
- B. Crutches
- C. A two-wheeled walker
- D. Parallel bars
Correct Answer: D
Rationale: After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.
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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.
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
- A. Hemoglobin
- B. Bilirubin
- C. Albumin
- D. Cortisol
Correct Answer: C
Rationale: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than3 \mathrm{~g}/\mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.
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.
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.
You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what?
- A. Patient performs range-of-motion exercises.
- B. Patient avoids placing her body weight on the healing site.
- C. Patient elevates her body parts that are susceptible to edema.
- D. Patient demonstrates the technique for massaging the wound site.
Correct Answer: B
Rationale: The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.