Nokea
An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility?
- A. Motivate the patient to walk in the afternoon rather than the morning.
- B. Encourage the patient to push through the pain in order to gain further mobility.
- C. Administer an analgesic as ordered to facilitate the patients mobility.
- D. Have another person with osteoarthritis visit the patient.
Correct Answer: C
Rationale: At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to push through the pain.
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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.
A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use?
- A. A cane
- B. Crutches
- C. A two-wheeled walker
- D. Parallel bars
Correct Answer: D
Rationale: After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.
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.
You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers?
- A. Turn and reposition the patient a minimum of every 8 hours.
- B. Vigorously massage lotion into bony prominences.
- C. Post a turning schedule at the patients bedside and ensure staff adherence.
- D. Slide, rather than lift, the patient when turning.
Correct Answer: C
Rationale: A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.
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.