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An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs?
- A. To provide an optimal learning environment with minimal distractions
- B. To describe the evidence base for any chosen interventions
- C. To help the patient become aware of the requirements of assisted-living centers
- D. To ensure that the patient is able to perform self-care without any aid from caregivers
Correct Answer: A
Rationale: The nurses role is to provide an optimal learning environment that minimizes distractions. Describing the evidence base is not a priority, though nursing actions should indeed be evidence-based. Assistedliving facilities are not relevant to most patients. Absolute independence in ADLs is not an appropriate goal for every patient.
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You are the rehabilitation nurse caring for a 25 -year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently?
- A. Complete a physical assessment.
- B. Evaluate the patients positioning.
- C. Plan nursing interventions.
- D. Assist the patient to ambulate.
Correct Answer: B
Rationale: During each patient contact, the nurse evaluates the patients position and assists the patient to achieve and maintain proper positioning and alignment. The nurse does not complete a physical assessment during each patient contact. Similarly, the nurse does not plan nursing interventions or assist the patient to ambulate each time the nurse has contact with the patient.
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.
The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply.
- A. Help the patient learn to apply and remove the orthosis.
- B. Teach the patient how to care for the skin that comes in contact with the orthosis.
- C. Assist in the initial fitting of the orthosis.
- D. Assist the patient in learning how to move the affected body part correctly.
- E. Collaborate with the physical therapist to set goals for care.
Correct Answer: A,B,D,E
Rationale: In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely or if it is adjusted improperly. Nurses do not perform the initial fitting of orthoses.
A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. You are the nurse planning the patients care. Who will the patients condition affect?
- A. Himself
- B. His wife and any children that still live at home
- C. Him and his entire family
- D. No one, provided he has a complete recovery
Correct Answer: C
Rationale: Patients and families who suddenly experience a physically disabling event or the onset of a chronic illness are the ones who face several psychosocial adjustments, even if the patient recovers completely.
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.