Nokea
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
- A. Hemoglobin
- B. Bilirubin
- C. Albumin
- D. Cortisol
Correct Answer: C
Rationale: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than3 \mathrm{~g}/\mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.
You may also like to solve these questions
The rehabilitation team has reaffirmed the need to maximize the independence of a patient in rehabilitation. When working toward this goal, what action should the nurse prioritize?
- A. Encourage families to become paraprofessionals in rehabilitation.
- B. Delegate care planning to the patient and family.
- C. Recognize the importance of informal caregivers.
- D. Make patients and families to work together.
Correct Answer: C
Rationale: In working toward maximizing independence, nurses affirm the patient as an active participant and recognize the importance of informal caregivers in the rehabilitation process. Nurses do not encourage families to become paraprofessionals in rehabilitation. The patient and family are central, but care planning is not their responsibility. Nurses do not make patients and families work together.
An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process?
- A. Most-responsible nurse
- B. Patient
- C. Patients family
- D. Primary care physician
Correct Answer: B
Rationale: The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
- A. Ineffective health maintenance
- B. Impaired physical mobility
- C. Disturbed sensory perception: Kinesthetic
- D. Ineffective role performance
Correct Answer: B
Rationale: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.
The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation?
- A. Stimulating the patients desire to ambulate
- B. Assessing the patients understanding of ambulation
- C. Helping the patient perform frequent exercise
- D. Setting realistic expectations
Correct Answer: C
Rationale: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulationwhether with brace, walker, cane, or crutchesthe patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation.
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.