8

Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health Problems
Test 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?
Physical therapist
Occupational therapist
Recreational therapist
Vocational therapist
a.
b.
c.
d.
ANS: B
The 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/Remembering
REF: p. 91
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Referrals)
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: C
There 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/Understanding
REF: p. 90
TOP: 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: A
To 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 higher
REF: N/A
TOP: 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: B
Participation 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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected 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?
Use the bear-hug method to transfer the client safely.
Ask several members of the health care team to assist.
Utilize the facilitys mechanical lift to move the client.
Consult physical therapy before performing all transfers.
a.
b.
c.
d.
ANS: C
Use 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.
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Ergonomic Principles)
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: C
The 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.
REF: p. 94
TOP: 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 calories
b. An occupational therapy consult
c. Bowel and bladder retraining
d. Upper arm strengthening exercises
ANS: D
With 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.
REF: N/A
Accident/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: D
Moving 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.

REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort
Mobility/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?
Apply shoes to improve foot support.
Perform weight-bearing activities.
Increase calcium-rich foods in the diet.
Use pressure-relieving devices.
a.
b.
c.
d.
ANS: B
Weight-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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Alterations in Body Systems)
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 motion
b. Active range of motion
c. Resistive range of motion
d. Aerobic exercise
ANS: B
Active 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.
REF: N/A
Systems)
11. The nurse is caring for a bedridden client. Which intervention will the nurse implement to
prevent pressure ulcer formation?

Adjust nutritional intake based on serum albumin levels.
Measure the ulcer diameter and depth every shift.
Change the gauze dressing whenever drainage is observed.
Apply antibiotic ointment to all excoriated skin areas.
a.
b.
c.
d.
ANS: A
Assessing 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.

REF: N/A
Complications from Surgical Procedures and Health Alterations)
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?

Range-of-motion exercises
Foot support while in bed
Increased dietary calcium intake
Avoidance of sudden position changes
a.
b.
c.
d.
ANS: A
Range-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.
REF: N/A
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?

Reduce hygiene activities and restrict visitors.
Ensure that the client toilets before and after planned activities.
Schedule energy-intensive activities when energy levels are high.
Schedule as many activities as possible in a small block of time.
a.
b.
c.
d.
ANS: C
Some 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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortRest and Sleep)
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: C
This 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.
REF: N/A
TOP: 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: D
At 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/Understanding
REF: p. 102
TOP: 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?

Carbonated beverages
Citric juices
Milk
Tomato juice
a.
b.
c.
d.
ANS: D
Some 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.
REF: N/A
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?
The client has skid-proof socks, so there is no need to use your gait belt.
Teach the client how to use her walker while you are ambulating up the hall.
Sit the client on the edge of the bed with legs dangling before ambulating.
Ask the client if she needs pain medication before you walk her in the hall.
a.
b.
c.
d.
ANS: C
Before 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.

REF: N/A
Accident/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?
To plan your care based on your normal elimination routine.
So we can help prevent side effects of your medications.
We need to evaluate your ability to function independently.
To schedule your activities around your elimination pattern.
a.
b.
c.
d.
ANS: A
Bowel 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.
REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
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: D
The 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.
REF: N/A
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: C
If 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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
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 thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting
ANS: B
With 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.
REF: N/A
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 pathologist
b. Nutritionist
c. Rehabilitation case manager
d. Cognitive therapist
ANS: A
Speech-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.
REF: N/A
Collaboration with Interdisciplinary Team)

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, D
The 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.
REF: p. 91
Collaboration with Interdisciplinary Team)
2. An older adult client tells the nurse, I tire easily. Which activities best assist the client to
conserve energy? (Select all that apply.)

Perform all tasks in the morning.
Take frequent rest periods.
Gather all supplies needed for a chore.
Use a cart, bag, or tray to carry items.
Push objects rather than lifting them.
Break large activities into smaller parts.
Hire someone to assist with chores.
a.
b.
c.
d.
e.
f.
g.
ANS: B, C, D, E, F
Major 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.
REF: N/A
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.
d.
e.
f.
Have the client do wheelchair pushups.

Remove the clients shoes to check for pressure areas.
Assess the clients lower legs for pressure from the wheelchair.
Massage the clients calves and feet with lotion.
ANS: A, C, D
Clients 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.
REF: N/A
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.)
Low serum albumin level
High serum transferrin level
Low serum carboxyhemoglobin
High serum hematocrit
Increased weight gain
Incontinence
Poor fluid intake
a.
b.
c.
d.
e.
f.
g.
ANS: A, E, F, G
A 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.
REF: N/A
Alterations in Body Systems)
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, F
Placing 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.
REF: N/A
Systems)
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-protein
b. Low-protein
c. High-carbohydrate
d. Low-carbohydrate
e. High-fat
f. Low-fat
ANS: A, C, F
The 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.
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral
Hydration)

8

Încărcat de

Informații document

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

8

Încărcat de

Drepturi de autor:

Formate disponibile

Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health Problems

the client before rehabilitation activities are begun?

in determining the severity of a clients disability?

d. Independent living skills test (ILST)

DIF: Cognitive Level: Application/Applying or higher

prevent pressure ulcer formation?

DIF: Cognitive Level: Application/Applying or higher

would be best to prevent venous stasis and thrombus formation?

to best conserve a clients energy without compromising physical or mental health?

will the nurse do next?

cost of the catheters. What is the nurses best response?

would be even higher.

At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis

should the nurse encourage the client to drink?

DIF: Cognitive Level: Application/Applying or higher

the client with bladder dysfunction?

c. Use the Cred maneuver every 3 hours.

bladder training using which technique?

MSC: Integrated Process: Communication & Documentation

conserve energy? (Select all that apply.)

implement to prevent skin breakdown? (Select all that apply.)

Have the client do wheelchair pushups.

S-ar putea să vă placă și