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The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply.
- A. Help the patient learn to apply and remove the orthosis.
- B. Teach the patient how to care for the skin that comes in contact with the orthosis.
- C. Assist in the initial fitting of the orthosis.
- D. Assist the patient in learning how to move the affected body part correctly.
- E. Collaborate with the physical therapist to set goals for care.
Correct Answer: A,B,D,E
Rationale: In addition to learning how to apply and remove the orthosis and maneuver the affected body part correctly, patients must learn how to properly care for the skin that comes in contact with the appliance. Skin problems or pressure ulcers may develop if the device is applied too tightly or too loosely or if it is adjusted improperly. Nurses do not perform the initial fitting of orthoses.
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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.
A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?
- A. Keep a record of when the incontinence occurs.
- B. Perform clean intermittent self-catheterization.
- C. Perform Kegel exercises four to six times per day.
- D. Wear a protective undergarment to address this age-related change.
Correct Answer: C
Rationale: For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.
You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient?
- A. Whole wheat macaroni with cheese
- B. Skim milk, oatmeal, and whole wheat toast
- C. Steak, baked potato, spinach and strawberry salad
- D. Eggs, hash browns, coffee, and an apple
Correct Answer: C
Rationale: The patient should be encouraged to eat foods high in protein, carbohydrates and vitamins A, B, and C. A meal of steak, baked potato, spinach and strawberry salad best exemplifies this dietary balance.
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.
You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action?
- A. You know that this patient will have a decreased level of consciousness.
- B. You know that this patient may not be motivated to prevent pressure ulcers.
- C. You know that the risk for pressure ulcers is directly related to the duration of immobility.
- D. You know that the risk for pressure ulcers is related to what caused the immobility.
Correct Answer: C
Rationale: The development of pressure ulcers is directly related to the duration of immobility: If pressure continues long enough, small vessel thrombosis and tissue necrosis occur, and a pressure ulcer results. The cause of the immobility is not what is important in the development of a pressure ulcer; the duration of the immobility is what matters. Paraplegia does not result in a decreased level of consciousness and there is no reason to believe that the patient does not want to prevent pressure ulcers.