Nokea
A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?
- A. Regular perineal care to prevent skin breakdown
- B. Kegel exercises to strengthen the pelvic floor
- C. Administration of hypotonic IV fluid
- D. Limited fluid intake to prevent incontinence
Correct Answer: A
Rationale: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.
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The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid?
- A. Scheduled toileting
- B. Indwelling catheter
- C. External condom catheter
- D. Incontinence pads
Correct Answer: B
Rationale: Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.
You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following?
- A. Dressing
- B. Bathing
- C. Feeding
- D. Meal preparation
Correct Answer: D
Rationale: Instrumental activities of daily living (IADLs) include grocery shopping, meal preparation, housekeeping, transportation, and managing finances. Activities of daily living (ADLs) include bathing dressing, feeding, and toileting.
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.
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing?
- A. Passive
- B. Isometric
- C. Resistive
- D. Abduction
Correct Answer: B
Rationale: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.
You are the nurse providing care for a patient who has limited mobility after a stroke. What would you do to assess the patient for contractures?
- A. Assess the patients deep tendon reflexes (DTRs).
- B. Assess the patients muscle size.
- C. Assess the patient for joint pain.
- D. Assess the patients range of motion.
Correct Answer: D
Rationale: Each joint of the body has a normal range of motion. To assess a patient for contractures, the nurse should assess whether the patient can complete the full range of motion. Assessing DTRs, muscle size, or joint pain do not reveal the presence or absence of contractures.