Exam (elaborations)
NURS 400 Unit 5
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Exam of 84 pages for the course cardiac exam nursing 400 at cardiac exam nursing 400 (NURS 400 Unit 5)
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NURS 400 Unit 5Chapter 13 Principles and Practices of Rehabilitation - ANS-
1. The nurse is providing care for an older adult man whose diagnosis of dementia has
recently led to urinary incontinence. When planning this patients care, what intervention
should the nurse avoid?
A) Scheduled toileting
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads - ANS-B
2. 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. - ANS-B
3. An elderly female patient who is bedridden is admitted to the unit because of a
pressure
ulcer that can no longer be treated in a community setting. During your assessment of
the
patient, you find that the ulcer extends into the muscle and bone. At what stage would
document this ulcer?
A) I
B) II
C) III
D) IV - ANS-D
4. A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is
currently receiving inpatient rehabilitation. You are coaching the patient to contract and
relax her muscles while keeping her extremity in a fixed position. Which type of exercise
is the patient performing?
A) Passive
,B) Isometric
C) Resistive
D) Abduction - ANS-B
5. 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 - ANS-B
6. 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 - ANS-A
7. 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 - ANS-B
8. The nurse is caring for an older adult patient who is receiving rehabilitation following
an
ischemic stroke. A review of the patients electronic health record reveals that the patient
usually defers her self-care to family members or members of the care team. What
should the nurse include as an initial goal when planning this patients subsequent care?
A) The patient will demonstrate independent self-care.
B) The patients family will collaboratively manage the patients care.
C) The nurse will delegate the patients care to a nursing assistant.
D) The patient will participate in a life skills program. - ANS-A
,9. You are caring for a 35-year-old man whose severe workplace injuries necessitate
bilateral below-the-knee amputations. How can you anticipate that the patient will
respond to this news?
A) The patient will go through the stages of grief over the next week to 10 days.
B) The patient will progress sequentially through five stages of the grief process.
C) The patient will require psychotherapy to process his grief.
D) The patient will experience grief in an individualized manner. - ANS-D
10. 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. - ANS-C
11. 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 - ANS-C
12. 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 - ANS-C
13. 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 - ANS-A
14. A female patient, 47 years old, visits the clinic because she has been experiencing
stress
incontinence when she sneezes or exercises vigorously. What is the best instruction the
nurse can give the patient?
A) Keep a record of when the incontinence occurs.
B) Perform clean intermittent self-catheterization.
C) Perform Kegel exercises four to six times per day.
D) Wear a protective undergarment to address this age-related change. - ANS-C
15. 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 - ANS-B
16. A patient has completed the acute treatment phase of care following a stroke and
the
patient will now begin rehabilitation. What should the nurse identify as the major goal of
the rehabilitative process?
A) To provide 24-hour, collaborative care for the patient
B) To restore the patients ability to function independently
C) To minimize the patients time spent in acute care settings
D) To promote rapport between caregivers and the patient - ANS-B
17. A 52-year-old married man with two adolescent children is beginning rehabilitation
following a motor vehicle accident. You are the nurse planning the patients care. Who
will the patients condition affect?
A) Himself
B) His wife and any children that still live at home
C) Him and his entire family
D) No one, provided he has a complete recovery - ANS-C
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