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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.
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An interdisciplinary team has been working collaboratively to improve the health outcomes of a young adult who suffered a spinal cord injury in a workplace accident. Which member of the rehabilitation team is the one who determines the final outcome of the process?
- A. Most-responsible nurse
- B. Patient
- C. Patients family
- D. Primary care physician
Correct Answer: B
Rationale: The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.
A nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care?
- A. Extended rehabilitation care
- B. Independent living
- C. Acute-care center treatment
- D. State institutions that provide care for life
Correct Answer: B
Rationale: There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not describe extended rehabilitation care, acute-care center treatment, or state institutions because these are not increasing in importance.
An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility?
- A. Motivate the patient to walk in the afternoon rather than the morning.
- B. Encourage the patient to push through the pain in order to gain further mobility.
- C. Administer an analgesic as ordered to facilitate the patients mobility.
- D. Have another person with osteoarthritis visit the patient.
Correct Answer: C
Rationale: At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patients level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to push through the pain.
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
- A. Hemoglobin
- B. Bilirubin
- C. Albumin
- D. Cortisol
Correct Answer: C
Rationale: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than3 \mathrm{~g}/\mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.
A home care nurse performs Chomsky visit to a patient who is soon being discharged from a rehabilitation facility. This initial visit is to assess what the patient can do and to see what he will need when discharged home. What does this help ensure for the patient?
- A. Social relationships
- B. Family assistance
- C. Continuity of care
- D. Realistic expectations
Correct Answer: C
Rationale: A home care nurse may visit the patient in the hospital, interview the patient and the family, and review the ADL sheet to learn which activities the patient can perform. This helps ensure that continuity of care is provided and that the patient does not regress, but instead maintains the independence gained while in the hospital or rehabilitation setting. This initial visit does not ensure social relationships, family assistance, or realistic expectations.