Nokea
A rehabilitation nurse is caring for an older adult client who states, 'I tire easily.' How should the nurse respond? (Select all that apply.)
- A. Make a schedule for completing major tasks in the morning.
- B. Use a cart to push your belongings instead of carrying them.
- C. Your family should hire someone who can assist you with daily chores.
- D. Plan to gather all of the supplies needed for a chore prior to starting the activity.
- E. Try to break large activities into smaller parts to allow rest periods between activities.
Correct Answer: B,D,E
Rationale: Using a cart reduces energy expenditure compared to carrying items. Gathering supplies before starting a chore minimizes unnecessary steps. Breaking large activities into smaller parts allows rest periods, helping manage fatigue. Scheduling major tasks in the morning is a good strategy but not listed as an option. Hiring assistance is not ideal as it does not promote independence.
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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 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 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 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.
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.