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The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patients electronic health record reveals that the patient usually defers her selfcare to family members or members of the care team. What should the nurse include as an initial goal when planning this patients subsequent care?
- A. The patient will demonstrate independent self-care.
- B. The patients family will collaboratively manage the patients care.
- C. The nurse will delegate the patients care to a nursing assistant.
- D. The patient will participate in a life skills program.
Correct Answer: A
Rationale: An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patients care, the patients care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.
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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.
The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid?
- A. Scheduled toileting
- B. Indwelling catheter
- C. External condom catheter
- D. Incontinence pads
Correct Answer: B
Rationale: Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.
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.
A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process?
- A. To provide 24-hour, collaborative care for the patient
- B. To restore the patients ability to function independently
- C. To minimize the patients time spent in acute care settings
- D. To promote rapport between caregivers and the patient
Correct Answer: B
Rationale: The goal of rehabilitation is to restore the patients ability to function independently or at a preillness or preinjury level of functioning as quickly as possible. Twenty-four hour care, rapport, and minimizing time in acute care are not central goals of rehabilitation.
An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (dbrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.