Nokea
You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-theknee amputations. How can you anticipate that the patient will respond to this news?
- A. The patient will go through the stages of grief over the next week to 10 days.
- B. The patient will progress sequentially through five stages of the grief process.
- C. The patient will require psychotherapy to process his grief.
- D. The patient will experience grief in an individualized manner.
Correct Answer: D
Rationale: Loss of limb is a profoundly emotional experience, which the patient will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the patients grief. The patient may or may not benefit from psychotherapy.
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A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors?
- A. Decreased residual volume
- B. Urethral stenosis
- C. Increased bladder capacity
- D. Decreased muscle tone
Correct Answer: D
Rationale: Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.
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.
You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what?
- A. Patient performs range-of-motion exercises.
- B. Patient avoids placing her body weight on the healing site.
- C. Patient elevates her body parts that are susceptible to edema.
- D. Patient demonstrates the technique for massaging the wound site.
Correct Answer: B
Rationale: The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.
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.
A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use?
- A. A cane
- B. Crutches
- C. A two-wheeled walker
- D. Parallel bars
Correct Answer: D
Rationale: After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.