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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.
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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.
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.
A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should highlight what salient risk factor for traumatic brain injury?
- A. Substance abuse
- B. Sports participation
- C. Anger mismanagement
- D. Lack of community resources
Correct Answer: A
Rationale: Of spinal cord injuries,50 % are related to substance abuse, and approximately50\%$ of all patients with traumatic brain injury were intoxicated at the time of injury. This association exceeds the significance of sports participation, anger mismanagement, or lack of community resources.
A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?
- A. Regular perineal care to prevent skin breakdown
- B. Kegel exercises to strengthen the pelvic floor
- C. Administration of hypotonic IV fluid
- D. Limited fluid intake to prevent incontinence
Correct Answer: A
Rationale: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.
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.