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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.
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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.
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.
The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation?
- A. Stimulating the patients desire to ambulate
- B. Assessing the patients understanding of ambulation
- C. Helping the patient perform frequent exercise
- D. Setting realistic expectations
Correct Answer: C
Rationale: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulationwhether with brace, walker, cane, or crutchesthe patient must strengthen the muscles required. Therefore, exercise is the foundation of preparation.
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.
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing?
- A. Passive
- B. Isometric
- C. Resistive
- D. Abduction
Correct Answer: B
Rationale: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.