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A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- A. Place pillows under the client's heels.
- B. Have the client do wheelchair push-ups.
- C. Perform wound care as prescribed.
- D. Massage the client's calves and feet with lotion.
Correct Answer: B
Rationale: Clients who are wheelchair-bound should perform wheelchair push-ups for at least 10 seconds every hour to relieve pressure on weight-bearing areas, reducing the risk of skin breakdown. Pillows under the heels may increase pressure, wound care treats existing ulcers, and massaging the calves in clients with decreased mobility risks embolization.
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A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?
- A. Stroking the medial aspect of the thigh.
- B. Valsalva maneuver
- C. Use the Credé maneuver
- D. Apply a Texas catheter with a leg bag.
- E. Frequent toileting
Correct Answer: B
Rationale: The Valsalva maneuver, which involves bearing down to increase intra-abdominal pressure, can help initiate voiding in clients with a flaccid bladder where the voiding reflex is not intact. The Credé maneuver is also appropriate but is listed separately, and the Valsalva maneuver is specifically highlighted as effective in this context. Stroking the thigh is for upper motor neuron issues, a Texas catheter is not suitable, and frequent toileting is used for uninhibited bladders.
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 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 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.
A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse perform? (Select all that apply.)
- A. Maintain the safety of adaptive devices by monitoring their function and making repairs.
- B. Coordinate rehabilitation team activities to ensure implementation of the plan of care.
- C. Assist clients to identify support services and resources for the continuation of services.
- D. Counsel clients and family members on strategies to cope with disability.
- E. Support the clients' choices by acting as an advocate for the client and family.
Correct Answer: B,E
Rationale: The rehabilitation nurse coordinates team activities to ensure the plan of care is implemented and advocates for the client and family. Maintaining adaptive devices is the role of a biomedical technician, assisting with support services is the social worker's role, andcounseling on coping strategies is handled by a clinical psychologist.