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Following admission, how soon must a comprehensive rehabilitation plan of care be implemented on a rehabilitation patient?
- A. 12 hours
- B. 24 hours
- C. 3 days
- D. 1 week
Correct Answer: B
Rationale: A comprehensive rehabilitation plan must be initiated within 24 hours of admission to the rehabilitation service. The results of the interdisciplinary assessment provide the basis for development of the plan of care. The team has 3 days from admission to review and revise the plan of care.
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The spinal cord injury patient has paralysis of all extremities and bowel and bladder disturbance. The nurse recognizes the injury as most likely occurring at what vertebral level?
- A. C1 to C2
- B. C3 to C4
- C. C2 to C7
- D. C4 to C7
Correct Answer: C
Rationale: The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis of all extremities and trunk, and has lost control of bowel and bladder function.
What is the primary difference between the rehabilitation of children and the rehabilitation of adults?
- A. Level of disability
- B. Body part involved
- C. Degree of disability
- D. Developmental potential
Correct Answer: D
Rationale: The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child.
The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a brain injury. Which assessment data would support the diagnosis?
- A. Frequently becomes violent.
- B. Becomes easily fatigued.
- C. Is depressed.
- D. Cannot add three numbers in his head.
Correct Answer: D
Rationale: Impaired cognition includes problems in thinking, impaired concentration, and impaired information processing.
What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?
- A. Loud sound
- B. Distended bladder
- C. Leg cramp
- D. Sudden chilling
Correct Answer: B
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.
The rehabilitation nurse recognizes that the majority of patients with head injuries show no abnormal neurologic findings and experience no loss of consciousness. How should the nurse categorize this type of brain injury?
- A. Mild
- B. Moderate
- C. Severe
- D. Catastrophic
Correct Answer: A
Rationale: Mild brain injury is characterized by no loss of consciousness and no abnormal neurologic findings.