Nokea
You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position?
- A. Use of an abduction pillow between the patients legs
- B. Alignment of the head with the spine using a pillow
- C. Support of the lower back with a small pillow
- D. Placement of trochanter rolls under the greater trochanter
Correct Answer: A
Rationale: Abduction pillows can be used to keep the hip in correct alignment if precautions are warranted following hip replacement. Trochanter rolls and back pillows do not achieve this goal.
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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 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.
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.
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 creating the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patients nursing care plan?
- A. Maintain joint mobility.
- B. Refer to social services.
- C. Ambulate three times every day.
- D. Perform passive range of motion twice daily.
Correct Answer: A
Rationale: The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. The other listed actions are interventions, not goals.