Question 1

When the nurse assesses reddened heels on the bed-bound stroke patient,the nurse modifies the care plan to include which intervention?

Accepted Answer

Elevation of the feet gets the weight off the heels and will allow them to heal.All other options are not helpful to damaged skin.Brisk massage may promote damage to the skin.Alcohol can be irritating and may further damage heel skin.

Question 2

The LPN/LVN making care assignments to nursing assistants would not assign a patient who has:

Accepted Answer

Nursing assistants are not assigned to patients who have an unstable condition.Care of an unstable patient does not fall into the scope of practice of the unlicensed personnel.

Question 3

When the confused resident pours his cereal in a cup and "drinks" it,the nurse should:

Accepted Answer

The nurse should leave the resident alone to feed himself independently.Staff should refrain from doing what the resident can do for himself.

Question 4

The 76-year-old stroke patient in a long-term care facility has sent his food tray back to the kitchen untouched for the second time today.The most effective intervention to increase nutrition would be to:

Accepted Answer

Taking the high-energy drink meets the immediate challenge of inadequate nutritional intake.Referral to the dietitian and sitting with the patient may be helpful.Offering to feed from a rejected tray is not supportive.

Question 5

The nurse reminds the nursing assistant that the purpose of locking the wheels of a wheelchair is to:

Accepted Answer

Fall prevention is the purpose of locking the wheels of a wheelchair.

Question 6

The nurse assessing an 85-year-old patient who has been on bed rest for a fractured hip finds the patient flushed with a temperature of 100° F,pulse of 100,and respiration rate of 24.The next intervention should be to assess:

Accepted Answer

The initial assessments are the cardinal signs of pneumonia.The breath sounds should be assessed next to determine the presence of any adventitious breath sounds.BP will also need to be assessed,but the breath sounds are more important with the signs and symptoms present.Abdominal distention is indicative of a gastrointestinal problem.Amount of urinary output is important to an ongoing assessment but not a priority in the present circumstances.

Question 7

When the nurse is assessing a bed-bound resident,a reddened area over the coccyx that does not blanch is discovered.The best intervention to prevent further skin damage is to:

Accepted Answer

Since this appears to be a stage 1 pressure area,the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area.A warm compress is not warranted.This patient will need to be turned every hour.Monitoring of the area should continue but does not meet the immediate need.

Question 8

The rehabilitation nurse describes a patient who is blind,works full time as a Spanish interpreter,and lives with his wife in a downtown apartment.The nurse classifies this person as:

Accepted Answer

The blindness is an impairment of vision that does not inhibit the patient from performing his job or enjoying a normal life.

Question 9

The obese resident who lies on her back because it is difficult to turn due to her weight has a pressure ulcer on her coccyx that is covered with a dressing.The most effective intervention to encourage independence is:

Accepted Answer

The trapeze allows for self-positioning and is less confining than are bed rails.The other options do not foster independence.

Question 10

The nurse is caring for a resident who has a security device for safety purposes.What intervention must the nurse include in the plan of care?

Accepted Answer

The need for continuing the use of the security device must be assessed every 4 to 8 hours.The patient should be visually checked every 30 minutes,and turned and skin assessed every 2 hours.

Question 11

The nurse planning a group TV activity in a long-term care facility would choose a channel that offers a(n):

Accepted Answer

Travel documentaries are colorful and do not have a plot to follow.Cartoons are juvenile,opera does not have universal appeal,and the two-part drama would require long attention spans and good short-term memory.

Question 12

Treatment resources that focus on restorative care for people with chronic illness and disabilities are: (Select all that apply.)

Accepted Answer

Outpatient clinics,long-term care facilities,home care,and rehabilitation agencies are sources of rehabilitation for people with chronic illness or disability.Hospice agencies focus on care of the dying patient.

Question 13

To motivate a frustrated stroke patient who is learning to walk again,the most effective motivational intervention the rehabilitation nurse could make is to:

Accepted Answer

Talking with someone who can truly understand the frustration is helpful.Showing a short movie on ambulation techniques may be an effective teaching tool,but it is not a motivational tool.Observing the resident is necessary but does not provide motivation.A 1-week break will interrupt progress that has been made,thus decreasing motivation.

Question 14

The nurse caring for the resident who is disoriented can provide the best care with which intervention?

Accepted Answer

Keeping a routine leads to less confusion.Changing assistive personnel care assignments frequently is confusing for the resident.Choosing clothing from an entire closet is overwhelming for the confused resident;rather,giving the resident a few items to choose from encourages autonomy without increasing confusion.Sedatives should not be given to treat confusion.

Question 15

The nurse cautions the 70-year-old patient who just had the cast removed from a broken arm that the immobility during the time he was in a cast can cause:

Accepted Answer

Immobility can cause loss of strength and flexibility in the older adult.

Question 16

The nurse instructing a family in the selection of a chair for an older adult with Parkinson's disease would stress selecting a chair that:

Accepted Answer

Sturdy arms assist in rising and sitting.Soft,low,and wide chairs cause a person to lean forward to rise and to "fall into" the chair to be seated.

Question 17

A resident with advanced Parkinson's disease stays in his wheelchair all day because it is too tiring to walk and he is fearful of falling.In order to increase mobility,the best intervention would be to:

Accepted Answer

Walking is the best exercise to prevent problems associated with immobility.The gait belt will make the resident more secure.Canes and crutches do not diminish the weakness or the fear of falling.

Question 18

The chief goal of a long-term care facility is to:

Accepted Answer

Promotion of independence is the chief goal,not complete autonomy.Other options are services directed at achieving increased independence.

Question 19

The charge nurse instructs the nursing assistants to answer the call lights promptly,especially for patients who are receiving:

Accepted Answer

People taking diuretics need to go to the bathroom frequently,and oftentimes urgently.Prompt attention to call lights will reduce the probability of the patient getting up unassisted.Diuretics may also cause orthostatic hypotension,which increases the risk for falling.

Question 20

To decrease the incidence of falls,the nurse will arrange for the replacement of:

Accepted Answer

Loose area rugs should be replaced with nonslip carpets.

Quiz 9: Chronic Illness and Rehabilitation