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You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care?
- A. Advice from his family
- B. Appropriate assistive devices
- C. A personal health care aide
- D. An assisted-living environment
Correct Answer: B
Rationale: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.
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A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
- A. Liaising with the patients insurer to describe the patients successes.
- B. Teaching the patient about the pathophysiology of her functional deficits.
- C. Eliciting ways to get the patient to express a positive attitude.
- D. Appraising the familys involvement in the patients ADLs.
Correct Answer: D
Rationale: The nurse should also be aware of the patients medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the familys involvement in the patients ADLs. It is not normally necessary to teach the patient about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.
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 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.
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.