Nokea
The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area?
- A. The patients elbows
- B. The soles of the patients feet
- C. The patients heels
- D. The patients knees
Correct Answer: C
Rationale: Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.
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A patient is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system? Using this system achieves what goal of the patients care?
- A. Minimizing costs of the patients care
- B. Maintaining continuity of the patients care
- C. Maintain the nursing care plan between diverse sites
- D. Keeping the primary care provider informed
Correct Answer: B
Rationale: A referral system maintains continuity of care when the patient is transferred to the home or to a long-term care facility. The interests of cost and of keeping the primary care provider informed are not primary. The nursing plan is likely to differ between sites.
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 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 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.
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.