Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health ProblemsTest Bank

MULTIPLE CHOICE

1.A paraplegic client is being evaluated for transfer to a rehabilitation unit. The nurse refers the client to which interdisciplinary team member for evaluation of activities of daily living?a.Physical therapistb.Occupational therapistc.Recreational therapistd.Vocational therapist

ANS:BThe occupational therapist is responsible for ADL training, the physical therapist for muscle strength, the vocational therapist for job training, and the recreational therapist for hobbies or pastime activities.

DIF:Cognitive Level: Knowledge/RememberingREF:p. 91TOP:Client Needs Category: Safe and Effective Care Environment (Management of CareReferrals)MSC:Integrated Process: Nursing Process (Planning)

2.The nurse is teaching a client who is a paraplegic about prescribed rehabilitation. The client verbalizes that he doesnt know why he should go. What is the nurses best response?a.Your doctor ordered rehabilitation, and he does know what is best for you.b.When new discoveries are made, people in rehabilitation programs benefit first.c.Rehabilitation will teach you how to maintain the functional ability you have.d.You are right. It will not benefit you. I will cancel the orders for rehabilitation.

ANS:CThere are many purposes for participating in rehabilitation programs, including disability prevention, maintenance of functional ability, and restoration of function. Without the special knowledge learned through rehabilitation, the client with a newly acquired disability may never learn the skills needed to prevent long-term problems or conserve energy.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 90TOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Nursing Process (Implementation)

3.The nurse is caring for a client who has long-standing chronic obstructive pulmonary disease (COPD) and is recovering from a stroke. Which intervention is a priority when activity tolerance is assessed during rehabilitation?a.Assess vital signs before, during, and after activity.b.Perform a daily cognitive assessment.c.Consult physical therapy to ambulate the client.d.Monitor the clients progress in self-care ability.

ANS:ATo see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A cognitive assessment is not necessary before basic activities are performed. A consultation would not provide data on activity tolerance, and monitoring of self-care ability does not directly reflect tolerance as vital signs do.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)MSC:Integrated Process: Nursing Process (Evaluation)

4.A client with a past history of angina had a total knee replacement. What will the nurse teach the client before rehabilitation activities are begun?a.Use analgesics even if you are not in pain.b.Take nitroglycerin prophylactically before beginning activity.c.Take anti-inflammatory medications before exercising.d.Do not exercise if you have knee pain.

ANS:BParticipation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. Nitroglycerin dilates coronary arteries within 5 minutes of use, ensuring that they will be ready to meet the demand during exercise.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)MSC:Integrated Process: Teaching/Learning

5.The rehabilitation nurse is caring for an obese client with new bilateral leg amputations. The nurse is planning to move the client from the bed to the chair. What is the best approach?a.Use the bear-hug method to transfer the client safely.b.Ask several members of the health care team to assist.c.Utilize the facilitys mechanical lift to move the client.d.Consult physical therapy before performing all transfers.

ANS:CUse mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug method and the use of several members of the team do not eliminate staff injuries. Physical therapy should be consulted but cannot be depended on for all transfers. Nursing staff must be capable of transferring a client safely.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlErgonomic Principles)MSC:Integrated Process: Nursing Process (Implementation)

6.The nurse is caring for a client in a rehabilitation center. Which test will best assist the nurse in determining the severity of a clients disability?a.Instrumental activities of daily living (IADL)b.Minimum data set (MDS)c.Functional independence measure (FIM)d.Independent living skills test (ILST)

ANS:CThe FIM attempts to quantify what the person actually does, whatever the diagnosis or impairment. Categories for assessment consist of self-care, sphincter control, mobility, locomotion, communication, and cognition. The functional independence measure is a uniform data set used for outcome data collection in the United States. IADL is a functional assessment tool carried out by numerous members of the interdisciplinary team in the health care setting. The MDS is used to assess nursing home residents in areas of motor ability, sensation, and cognition, as well as overall health status.

DIF:Cognitive Level: Knowledge/RememberingREF:p. 94TOP:Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems)MSC:Integrated Process: Nursing Process (Assessment)

7.The nurse is planning care for a client who is newly wheelchair bound owing to a spinal cord injury. What priority intervention should the nurse include in the plan of care to assist the client in transferring from the bed to the wheelchair?a.A diet high in protein and low in caloriesb.An occupational therapy consultc.Bowel and bladder retrainingd.Upper arm strengthening exercises

ANS:DWith impaired mobility and use of a wheelchair, the client tends to gain weight. During rehabilitation, the client should be on a high-protein diet but not calorie restriction. The increased weight requires greater upper body strength for movement. The nurse should encourage the client to perform exercises that strengthen the upper arms. The nurse should consult physical therapy to assist with these exercises. Occupational therapy would not be involved in movement of the client but would be involved with ADLs. Bowel and bladder retraining may prevent skin breakdown but has nothing to do with the clients ability to transfer to the wheelchair.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)MSC:Integrated Process: Nursing Process (Assessment)

8.The nurse is performing passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. What action by the nurse is best?a.Splint the joint and continue passive range of motion to the shoulder only.b.Progressively increase joint motion 5 degrees beyond resistance each day.c.Apply weights to the right distal extremity before initiating any joint exercise.d.Continue to move the joint only to the point at which resistance is met.

ANS:DMoving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance. Splinting the joint will not assist the clients range of motion. The clients joint should not be forced. Applying weights to the extremity will not increase range of motion of the joint but most likely will cause damage.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortMobility/Immobility)MSC:Integrated Process: Nursing Process (Intervention)

9.The nurse is caring for a client with decreased mobility. What intervention should the nurse include in the care plan to best help this client decrease the risk of fracture?a.Apply shoes to improve foot support.b.Perform weight-bearing activities.c.Increase calcium-rich foods in the diet.d.Use pressure-relieving devices.

ANS:BWeight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Although increasing calcium in the diet is a good intervention, this alone will not reduce the clients susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)MSC:Integrated Process: Nursing Process (Implementation)

10.The nurse assesses a client admitted for rehabilitation. The client has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?a.Passive range of motionb.Active range of motionc.Resistive range of motiond.Aerobic exercise

ANS:BActive range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems)MSC:Integrated Process: Nursing Process (Implementation)

11.The nurse is caring for a bedridden client. Which intervention will the nurse implement to prevent pressure ulcer formation?a.Adjust nutritional intake based on serum albumin levels.b.Measure the ulcer diameter and depth every shift.c.Change the gauze dressing whenever drainage is observed.d.Apply antibiotic ointment to all excoriated skin areas.

ANS:AAssessing serum albumin levels helps determine the clients nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Implementation)

12.The nurse is caring for a client who is undergoing rehabilitation. Which nursing intervention would be best to prevent venous stasis and thrombus formation?a.Range-of-motion exercisesb.Foot support while in bedc.Increased dietary calcium intaked.Avoidance of sudden position changes

ANS:ARange-of-motion exercises involve skeletal muscle contraction of the upper and lower extremities. Muscle contraction promotes venous return, preventing stasis and thrombus formation. Foot support can help prevent contractures and foot drop. Increased calcium is not related to venous stasis and thrombus formation, nor is avoiding sudden position changes.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Implementation)

13.The nurse is caring for a rehabilitation client. Which activity plan should the nurse implement to best conserve a clients energy without compromising physical or mental health?a.Reduce hygiene activities and restrict visitors.b.Ensure that the client toilets before and after planned activities.c.Schedule energy-intensive activities when energy levels are high.d.Schedule as many activities as possible in a small block of time.

ANS:CSome of the best techniques for energy conservation include spacing activities with a rest period in between, and individualizing the scheduling of more energy-intensive activities to the time of day when the client knows or feels that his or her energy levels are higher.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortRest and Sleep)MSC:Integrated Process: Nursing Process (Implementation)

14.A nurse catheterizes a client immediately after voiding. The residual volume is 50 mL. What will the nurse do next?a.Notify the physician.b.Insert an indwelling catheter.c.Document the finding in the chart.d.Modify the bladder training program.

ANS:CThis finding is normal. Therefore, the nurse should document the finding and continue with the present bladder training program. The goals of a bladder training program are to avoid the use of an indwelling catheter and to keep the residual volume at less than 100 mL.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortElimination)MSC:Integrated Process: Nursing Process (Evaluation)

15.The client who is performing intermittent self-catheterization at home is concerned about the cost of the catheters. What is the nurses best response?a.I will try to find out whether you qualify for money to purchase these necessary supplies.b.Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.c.Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.d.You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.

ANS:DAt home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client to the social worker to explore financial concerns. The nurse should not threaten the client, nor should the client be instructed to boil the catheters.

DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 102TOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortElimination)MSC:Integrated Process: Teaching/Learning

16.The nurse is providing education for a client at risk for urinary tract infection. Which beverage should the nurse encourage the client to drink?a.Carbonated beveragesb.Citric juicesc.Milkd.Tomato juice

ANS:DSome organisms, such as Escherichia coli, do not grow well in an acidic environment. Fluids that promote an acidic urine include cranberry juice, prune juice, bouillon, tomato juice, and water.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Nursing Process (Implementation)

17.The nurse delegates the unlicensed nursing assistant (UAP) to ambulate an older adult client. What information must the nurse communicate to the UAP when delegating this task?a.The client has skid-proof socks, so there is no need to use your gait belt.b.Teach the client how to use her walker while you are ambulating up the hall.c.Sit the client on the edge of the bed with legs dangling before ambulating.d.Ask the client if she needs pain medication before you walk her in the hall.

ANS:CBefore the client gets out of bed, have the client sit on the bed with legs dangling on the side. This will enhance safety for the client. The UAP cannot assess the clients pain or teach the client to use a walker. A gait belt should be used for all clients.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention)MSC:Integrated Process: Communication & Documentation

18.The nurse is obtaining an admission history of a client with hip problems. The client asks, Why are you asking about my bowels and bladder? What is the nurses best response?a.To plan your care based on your normal elimination routine.b.So we can help prevent side effects of your medications.c.We need to evaluate your ability to function independently.d.To schedule your activities around your elimination pattern.

ANS:ABowel elimination varies from client to client and must be evaluated on the basis of the clients normal routine. The nurse asks about bowel and bladder to develop a client-centered plan of care. The other answers are correct but are not the best response. Oral analgesics may cause constipation, but they do not interfere with bladder control. Elimination usually is scheduled around rehabilitation activities but should be taken into consideration when a plan of care is developed. The client is in rehabilitation to assist her or his ability to function independently.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Psychosocial Integrity (Therapeutic Communication)MSC:Integrated Process: Communication & Documentation

19.The nurse is planning care for a client who is beginning a structured cardiac rehabilitation program. Before starting the program, what should the nurse do first?a.Administer nitroglycerin to increase blood flow to the heart.b.Assess the client for orthostatic hypotension.c.Start oxygen at 2 L/min via nasal cannula.d.Determine the level of activity before shortness of breath occurs.

ANS:DThe level of activity that can be accomplished without experiencing shortness of breath needs to be established before activity is begun. This will alleviate fear and anxiety and will prevent the occurrence of cardiac symptoms. Oxygen should be started only if the pulse oximetry reading is below 90%, or if electrocardiographic changes or cardiac symptoms occur, none of which is indicated in this question. Nitroglycerin should be given only if the client has a history of angina. Orthostatic hypotension should be assessed before a client is ambulated, but this assessment does not provide information specific to the clients cardiac rehabilitation program.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)MSC:Integrated Process: Nursing Process (Assessment)

20.The nurse is caring for a client with a spinal cord injury at level T3. How will the nurse assist the client with bladder dysfunction?a.Insert an indwelling urinary catheter.b.Stroke the medial aspect of the thigh.c.Use the Cred maneuver every 3 hours.d.Apply a Texas catheter with leg bag.

ANS:CIf the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag. Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Cred maneuver. Indwelling urinary catheters generally are noted used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management)MSC:Integrated Process: Nursing Process (Implementation)

21.A client with a flaccid bladder is undergoing bladder training. The nurse begins the clients bladder training using which technique?a.Stroking the medial aspect of the thighb.Valsalva maneuverc.Self-catheterizationd.Frequent toileting

ANS:BWith a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voidingthe Valsalva and Cred maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to re-establish voiding continence with an uninhibited bladder.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems)MSC:Integrated Process: Nursing Process (Planning)

22.The nurse is caring for a client after a stroke. The client has a right facial droop, drools continuously, and chokes on her own saliva. What rehabilitation team member should the nurse consult to ensure client safety?a.Speech-language pathologistb.Nutritionistc.Rehabilitation case managerd.Cognitive therapist

ANS:ASpeech-language pathologists (SLPs) evaluate and retrain clients with speech, language, or swallowing problems. Nutritionists may be needed to ensure that clients meet their nutritional needs. Rehabilitation case managers coordinate the efforts of health care team members. Cognitive therapists, usually neuropsychologists, work primarily with clients who have experienced head injury with cognitive impairment.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team)MSC:Integrated Process: Communication & Documentation

MULTIPLE RESPONSE

1.The nurse collaborates with a physical therapist when providing care for a rehabilitation client. The role of the physical therapist is to help the client with which activities? (Select all that apply.)a.Achieve mobility.b.Attain independence with dressing.c.Use a walker in public.d.Learn techniques for transferring.e.Perform activities of daily living.f.Complete job training.

ANS:A, C, DThe role of the physical therapist is to assist in muscle strength development and ambulation. The occupational therapist deals with ADLs, dressing, and activities needed for job training.

DIF:Cognitive Level: Knowledge/RememberingREF:p. 91TOP:Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team)MSC:Integrated Process: Nursing Process (Implementation)

2.An older adult client tells the nurse, I tire easily. Which activities best assist the client to conserve energy? (Select all that apply.)a.Perform all tasks in the morning.b.Take frequent rest periods.c.Gather all supplies needed for a chore.d.Use a cart, bag, or tray to carry items.e.Push objects rather than lifting them.f.Break large activities into smaller parts.g.Hire someone to assist with chores.

ANS:B, C, D, E, FMajor tasks should be performed in the morning, when energy levels are high. Lesser tasks should be done throughout the day after frequent rest periods. Gathering equipment before performing a chore decreases unneeded steps. Carrying more than one or two items at a time saves time and energy. It takes less energy to push items than to carry them. Breaking larger chores into smaller ones allows rest periods between activities and gives the client a sense of completion if unable to complete the whole task. Someone should be hired to do the chores only if the client cannot do them. The outcome should be achieving independence as close as possible to the pre-disability level.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Nursing Process (Implementation)

3.The nurse is caring for a client who is wheelchair bound. Which interventions will the nurse implement to prevent skin breakdown? (Select all that apply.)a.Change the clients position every 1 to 2 hours.b.Place pillows under the clients heels.c.Have the client do wheelchair pushups.d.Remove the clients shoes to check for pressure areas.e.Assess the clients lower legs for pressure from the wheelchair.f.Massage the clients calves and feet with lotion.

ANS:A, C, DClients who sit for prolonged periods in a wheelchair need to be repositioned at least every 1 to 2 hours. Wheelchair push-ups should be done for at least 10 seconds every hour. If the client is wearing tennis shoes to prevent foot drop, the shoes should be removed every 2 hours to check for pressure areas. The lower legs, where the wheelchair could rub against the legs, also needs to be assessed. Pillows under the heels could exert pressure on the heels. It is better to place the pillow under the ankle. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Health Promotion and Maintenance (Self-Care)MSC:Integrated Process: Nursing Process (Implementation)

4.The nurse is caring for a client with a disabling condition. Which abnormal findings would alert the nurse to an increased risk for skin breakdown? (Select all that apply.)a.Low serum albumin levelb.High serum transferrin levelc.Low serum carboxyhemoglobind.High serum hematocrite.Increased weight gainf.Incontinenceg.Poor fluid intake

ANS:A, E, F, GA low serum albumin level indicates less than adequate nutrition, especially of proteins; this greatly increases the risk for skin breakdown and reduces the rate of wound healing. Protein is a critical nutrient for stimulating DNA synthesis, cell division, and tissue repair. Increased weight gain makes it more difficult to move and puts more pressure on pressure areas. Incontinence of bowel or bladder irritates the skin, making it more prone to breakdown.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)MSC:Integrated Process: Nursing Process (Assessment)

5.The nurse is caring for a client with left-sided weakness. Which gait-training techniques will the physical therapist and the nurse use when assisting the client to walk with a cane? (Select all that apply.)a.Place the cane in the clients left hand.b.Hold the cane with the clients stronger hand.c.Move the cane forward, followed by legs stepping forward.d.Take one step forward, followed by the cane moving forward.e.Step forward with the stronger leg, then the weaker leg.f.Move the weaker leg one step forward, followed by the stronger leg.

ANS:B, C, FPlacing the cane in the clients weaker hand does not provide sufficient stability. After the cane in the stronger hand is moved ahead, the cane and the stronger leg provide a stable base for movement of the weaker leg.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems)MSC:Integrated Process: Nursing Process (Implementation)

6.The nurse is implementing nutritional changes to reduce the risk for skin breakdown in a client with impaired physical mobility. Which dietary modifications will the nurse reinforce? (Select all that apply.)a.High-proteinb.Low-proteinc.High-carbohydrated.Low-carbohydratee.High-fatf.Low-fat

ANS:A, C, FThe goal of nutrition therapy is to provide sufficient nutrients to promote wound healing, prevent skin breakdown, and avoid gaining excessive weight. The two most important nutrients to stimulate cell division and prevent loss of muscle mass are carbohydrates and proteins.

DIF:Cognitive Level: Application/Applying or higherREF:N/ATOP:Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration)MSC:Integrated Process: Nursing Process (Implementation)