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You are the rehabilitation nurse caring for a 25 -year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently?
- A. Complete a physical assessment.
- B. Evaluate the patients positioning.
- C. Plan nursing interventions.
- D. Assist the patient to ambulate.
Correct Answer: B
Rationale: During each patient contact, the nurse evaluates the patients position and assists the patient to achieve and maintain proper positioning and alignment. The nurse does not complete a physical assessment during each patient contact. Similarly, the nurse does not plan nursing interventions or assist the patient to ambulate each time the nurse has contact with the patient.
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While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
- A. Ineffective health maintenance
- B. Impaired physical mobility
- C. Disturbed sensory perception: Kinesthetic
- D. Ineffective role performance
Correct Answer: B
Rationale: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.
You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following?
- A. Dressing
- B. Bathing
- C. Feeding
- D. Meal preparation
Correct Answer: D
Rationale: Instrumental activities of daily living (IADLs) include grocery shopping, meal preparation, housekeeping, transportation, and managing finances. Activities of daily living (ADLs) include bathing dressing, feeding, and toileting.
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.
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.
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.