Brunner And Suddarth’s Medical Surgical Nursing 12th Edition By Suzanne – Test Bank

Chapter: Chapter 11: Principles and Practices of Rehabilitation

Multiple Choice

1. Rehabilitation nursing deals with many and a variety of problems. When caring for a male patient with urinary incontinence, what intervention would the nurse avoid with this patient?
A) Intermittent self-catheterization
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Page and Header: 192, Assessment and Functional Ability

Feedback: Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voidings are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.

2. You are the nurse caring for a patient with a pressure ulcer. The nurse on the shift before you has done patient teaching about pressure ulcers and what the patient can do to help heal the pressure ulcer. You assess that the patient has understood the teaching by observing what?
A) Patient performs range-of-motion exercises
B) Patient avoids pressure on the healing site
C) Patient elevates body parts susceptible to edema
D) Patient demonstrates improved level of consciousness

Ans: B
Chapter: 11
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Page and Header: 185, Assessment and Functional Ability

Feedback: The major goals may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.

3. An elderly female patient who is bedridden is admitted to the unit because of a large pressure ulcer. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. What stage would document this ulcer?
A) I
B) II
C) III
D) IV

Ans: D
Chapter: 11
Client Needs: A-1
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Page and Header: 190, Assessment and Functional Ability

Feedback: Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

4. Part of the care given to rehabilitation patients is teaching them different ways to exercise their limbs, no matter what the patient is rehabbing for. You are the nurse assisting a stroke patient to exercise. You are coaching the patient to contract and relax her muscles while keeping the extremity in a fixed position. Which type of exercise is the patient completing?
A) Passive
B) Isometric
C) Resistive
D) Abduction

Ans: B
Chapter: 11
Client Needs: B
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 6
Page and Header: 178, Assessment and Functional Ability

Feedback: Isometric exercises are those in which there are alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.

5. The definition of rehabilitation is a team of professionals working together with the patient and the family. Which member of the rehabilitation team is the one who determines the final outcome of the process?
A) Nurse
B) Patient
C) Family
D) Doctor

Ans: B
Chapter: 11
Client Needs: D-4
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Page and Header: 169, The Rehabilitation Team

Feedback: The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The nurse, family, and doctor are part of the rehabilitation team but do not determine the final outcome.

6. The Americans with Disabilities Act (ADA), passed in 1990, is civil rights legislation designed to do what?
A) Provide access to the community to those with disabilities
B) Guarantee a job to those with disabilities
C) Provide an above-average income for those who are disabled
D) Make sure those who are disabled are well cared for

Ans: A
Chapter: 11
Client Needs: A-2
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Page and Header: 168, Americans with Disabilities Act

Feedback: In 1990, the U.S. Congress passed the Americans With Disabilities Act (ADA) (PL 101-336), which is civil rights legislation designed to provide people with disabilities access to job opportunities and to the community. It was not designed to guarantee a job, provide an above-average income, or make sure the person who is disabled is well cared for.

7. A nurse is giving a talk to a local community group about those who are disabled in the community. The group is interested in what trends are impacting the care of people who are disabled in the community. What would the nurse be sure to mention in her talk?
A) Extended rehabilitation care
B) Independent living
C) Acute-care center treatment
D) State institutions that provide care for life

Ans: B
Chapter: 11
Client Needs: C
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 9
Page and Header: 197, Promoting Home and Community-Based Care

Feedback: There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not talk about extended rehabilitation care, acute-care center treatment, or state institutions.

8. A patient is recovering from a stroke. The nurse notes that the patient is unwilling to attempt any self-care. What should the nurse include as an initial goal?
A) The patient will demonstrate independent self-care.
B) The patient’s family will manage the patient’s care.
C) The nurse will delegate the patient’s care to a nursing assistant.
D) The patient will participate in a social program.

Ans: A
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Page and Header: 167, Introduction

Feedback: An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patient’s care, the patient’s care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.

9. You are caring for a 35-year-old male who has just been diagnosed with paralysis due to a sky diving accident that injured the spinal cord. How can you anticipate that the patient will react emotionally?
A) Go through all stages of grief in a week so he can adapt
B) Progress sequentially through five stages of the grief process
C) Need humor therapy
D) Respond to grief in an individualistic manner

Ans: D
Chapter: 11
Client Needs: D-3
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Caring
Objective: 3
Page and Header: 168, Patients’ Reactions to Disability

Feedback: The most frequently reported chronic illness and disability-triggered reactions include shock, which is a short-lived reaction experienced at the onset of a traumatic and sudden injury or the onset of a life-threatening or chronic and debilitating disease; anxiety, which is a panic-like state as the nature and magnitude of the event is processed; denial, which is a defense mechanism used to ward off anxiety and other intense emotions; depression, which reflects the realization of the permanence and magnitude of the chronic illness or disability; anger and hostility that are both self-directed and externalized; and adjustment, which is exemplified by self-acceptance as a person with a chronic illness or disability and marked by reintegration into the community. Finally, chronic illness and disability-associated coping strategies are those psychological strategies that are used to decrease, modify, or diffuse the impact of stressful life events. Humor is a coping strategy that some people use, but people going through life-altering events do not need humor therapy at this point.

10. An elderly female diagnosed with osteoarthritis has been admitted to your unit. The patient has difficulty ambulating because of chronic pain. What intervention may the nurse use to help with the patient’s mobility?
A) Motivate the patient to walk in the afternoon
B) Determine if self-care devices are needed
C) Administer an analgesic as ordered to increase mobility
D) Have another person with osteoarthritis visit the patient

Ans: C
Chapter: 11
Client Needs: D-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Page and Header: 174, Assessment and Functional Ability

Feedback: At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (eg, cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patient’s level of comfort during ambulation and allow the patient to ambulate. The nurse should plan for ambulation with the patient and administer the analgesic in advance of the ambulation to allow sufficient time for the analgesic to take action. Motivating the patent or having another person with the same diagnosis visit are not interventions that will help with mobility. Determining if self-care devices are needed is a collaborative assessment; it is not an intervention.