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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.
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A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
- A. Splint the joint and continue passive range of motion to the shoulder only.
- B. A passive range of motion to the right elbow and the right knee back to the right.
- C. Apply weights to the right distal extremity before initiating any joint exercise.
- D. Continue to move the joint only to the point at which resistance is met.
Correct Answer: D
Rationale: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance to prevent injury. Splinting the joint will not assist the client's range of motion and may restrict it further. The option of passive range of motion to the elbow and knee is unclear and not a standard practice. Applying weights to the extremity will not increase range of motion and could cause harm.
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.
A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
- A. Nutritional intake and serum albumin levels
- B. Pressure ulcer diameter and depth
- C. Wound drainage, including color, odor, and consistency
- D. Dressing site and antibiotic ointment application
Correct Answer: A
Rationale: Assessing nutritional intake and serum albumin levels helps determine the client's nutritional status, which is critical for preventing pressure ulcers, as poor nutrition can impair skin integrity. The other options focus on treating existing pressure ulcers rather than preventing their formation.
A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity violence?
- A. Vital signs before, during, and after activity
- B. Body image and self-care abilities
- C. Vital signs use and self-care device devices
- D. Clients electrocardiography readings
Correct Answer: A
Rationale: To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.
A nurse teaches a client about performing intermittent self-catheterization. The client states, 'I am not sure if I will be able to afford these catheters.' How should the nurse respond?
- A. You may qualify for financial assistance; let's discuss options with a social worker.
- B. Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.
- C. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.
- D. You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.
Correct Answer: D
Rationale: Using clean technique for intermittent self-catheterization at home is sufficient to prevent urinary tract infections and reduces costs by allowing catheter reuse after proper cleaning. Referring to a social worker for financial concerns is appropriate but not the most direct response to the client's concern. Boiling catheters is not a recommended practice, and emphasizing the cost of infections may cause anxiety without addressing the issue.