NUR 216F 08

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TomWruble
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250339
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NUR 216F 08
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2013-12-04 09:38:41
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Rehabilitation Concepts Chronic Disabling Health Problems
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Rehabilitation Concepts for Chronic and Disabling Health Problems
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  1. Areas at risk for Pressure Ulcers
    • Occiput
    • Ears
    • Scapula
    • Elbow
    • Sacrum
    • Ischial Tuberosities
    • Greater Trochanter
    • Medial condyle of Tibia
    • Fibular Head
    • Medial Malleolus
    • Lateral Malleolus
    • Heel
  2. ˜Reflex (spastic) bowel
    upper motor neuron disease/injury

    defecation occurs suddenly without warning
  3. ˜Flaccid bowel
    lower motor neuron disease/injury

    defecation occurs infrequently and in small amounts
  4. ˜Uninhibited bowel
    brain injury

    frequent defecation, urgency, hard stool
  5. Bowel Training
    • ˜Combination of suppository use
    • consistent toileting schedule˜
    • Bisacodyl (Dulcolax)˜
    • Fluids˜
    • Fiber
    • ˜Bedside commode˜
    • Metamucil
  6. Pressure Ulcer Stage I
    Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

    The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk” persons (a heralding sign of risk)
  7. Pressure Ulcer Stage II
    Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

    Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.*Bruising indicates suspected deep tissue injury
  8. Pressure Ulcer Stage III
    Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

    The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
  9. Pressure Ulcer Stage IV
    Full thickness tissue loss with exposed bone, tendon or muscle.

    Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

    The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
  10. Pressure Ulcer Unstagable
    Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
  11. Spastic or reflex bladder
    (upper motor neuron)

    incontinence with sudden, gushing voids
  12. Flaccid or areflexic bladder
    lower motor neuron

    urinary retention and overflow (dribbling)
  13. Uninhibited bladder—similar to a reflex bladder. Frequently occurs when the patient has a neurologic problem that affects the brain’s bladder center in the frontal lobe
    similar to a reflex bladder.

    Frequently occurs when the patient has a neurologic problem that affects the brain’s bladder center in the frontal lobe
  14. The Credé's maneuver
    is a technique used to void urine from the bladder of an individual who, due to disease, cannot do so without aid. The Credé's maneuver is executed by holding manual pressure just over the anterior surface of the skin, where the bladder is located.
  15. Chronic disease accounts for about
    70% of all deaths.
  16. A patient who is morbidly obese has a history of urinary tract infections with Escherichia coli. He has just passed a kidney stone. The nurse should encourage which fluid to minimize the risk for urinary problems?

    A. Water
    B. Cranberry juice
    C. Citrus juice
    D. Fruit-flavored drink
    For this patient, it should be remembered that E. coli grows best in an acidic environment, which may be enhanced by the intake of cranberry juice. In addition, fluids that promote an alkaline urine, such as citrus juices, should be discouraged because of the history of renal calculi (stones). High-calorie fluids should be avoided for overweight patients. Water is the preferred liquid to help prevent urinary problems.
  17. The nurse is assessing a patient who has been newly admitted to a rehabilitation unit after recovering from a stroke. The patient reports, when asked, that he usually has a bowel movement every third day. What should the nurse do next?

    A. The nurse concludes that the patient is constipated.
    B. The nurse asks if this pattern is normal for him.
    C. The nurse offers him a laxative.
    D. The nurse assesses the patient's bowel sounds.
    B. The nurse asks if this pattern is normal for him.

    Bowel habits are evaluated on the basis of what is normal for that person. Note any changes in the patient’s bowel routine or stool consistency. If the patient reports any change in elimination pattern, try to determine whether it is due to a change in diet, activity pattern, or medication use. A thorough history and assessment should be completed before assuming the patient is constipated.
    (this multiple choice question has been scrambled)
  18. The nurse is assisting a patient with ambulation. The patient has general weakness but is able to walk. Which measure will best prevent potential falls due to orthostatic hypotension?

    A. Teach the patient to first sit on the side of the bed for a few minutes before standing slowly.
    B. Have the patient move from a lying to standing position slowly.
    C. Administer the patient's antihypertensive medications 1 hour before ambulation.
    D. Hold the patient's antihypertensive medication until after the ambulation session.
    A. Teach the patient to first sit on the side of the bed for a few minutes before standing slowly.

    C might work, but D is "best"

    Orthostatic, or postural, hypotension is a common problem in rehabilitation and contributes to falls, which are common in any patient with impaired mobility. If the patient moves from a lying to a sitting or standing position too quickly, his or her blood pressure drops. As a result, he or she becomes dizzy or faints. This problem is worsened by antihypertensive drugs, especially in older adults. To prevent this situation, help the patient change positions slowly, with frequent rest periods to allow the blood pressure to stabilize.
    (this multiple choice question has been scrambled)
  19. An uninhibited bladder does/does not routinely require medication for bladder training.
    not
  20. Cholinergics such as AAA may decrease urinary retention problems resulting from a BBB bladder.
    • A) bethanechol chloride (Urecholine)
    • B) flaccid
  21. AAA suppository agents are often used in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the sacral arc and promote rectal emptying, which occurs within BBB after administration.
    • A) Glycerin
    • B) 15 to 30 minutes
  22. Metamucil may bind with some drugs, such as AAA, BBB and CCC, and prevent their absorption. Timing of this drug is best when it is separated from other prescribed drugs by at least DDD.
    • A) anticoagulants
    • B) thyroid replacements
    • C) digoxin
    • D) 3 hours
  23. For patients at risk for constipation, encourage fluids and plenty of fiber in the diet, such as ...
    whole grains, celery, fruits, and nuts
  24. Which of these nursing interventions can the rehabilitation nurse delegate to a nursing assistant who is caring for a 70-year-old patient who has right-sided weakness after a stroke?

    A. Reinforce placing the right arm in the sleeve first when dressing.
    B. Teach the patient to use an extended shoe horn when putting on shoes.
    C. Determine whether the patient’s passive range of motion should be increased.
    D. Arrange for family members to participate in planning for discharge.
    A. Reinforce placing the right arm in the sleeve first when dressing.

    Reinforcement of skills that have been taught by the occupational therapist or nurse is an action that should be done by all caregivers who are involved in the patient's care.

    Teaching, assessment, and planning for discharge require more education and scope of practice and should be done by licensed staff members.
    (this multiple choice question has been scrambled)
  25. Because new redness over a bony area may indicate the presence of a stage I pressure ulcer, the nurse should assess this patient's skin as soon as possible and implement interventions to improve skin integrity. The other patients also need assessment and intervention but are not as at high a risk for ...
    acute physiologic complications
  26. A patient with a traumatic brain injury is admitted to the rehabilitation unit. Which of these members of the rehabilitation team will the nurse assign to develop a plan to improve the patient's ability to bathe and dress independently?

    A. Cognitive therapist
    B. Physical therapist
    C. Occupational therapist
    D. Activity therapist
    C. Occupational therapist

    Occupational therapists work with patients to develop skills used for self-care, such as hygiene and dressing. The other therapists are also part of the team but will assist the patient with other aspects of rehabilitation.
    (this multiple choice question has been scrambled)
  27. The nursing assistant asks the rehabilitation nurse for assistance in transferring a 320-pound patient from the bed to a wheelchair. Which action should the nurse take next?

    A. Check the physical therapy care plan.
    B. Ask additional staff members for assistance.
    C. Obtain the mechanical patient lift.
    D. Help the nursing assistant with the transfer.
    A. Check the physical therapy care plan.

    The physical or occupational therapist is usually responsible for assessing a patient's ability to transfer and specifying the type of transfer. The other actions may be appropriate for the nurse to take, depending on the physical therapy care plan.
    (this multiple choice question has been scrambled)
  28. A patient with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL in the bladder. Which of these actions included on the bladder training plan should the nurse take next?

    A. Insert a straight catheter and empty the bladder.
    B. Reassess the bladder volume in 2 hours.
    C. Give bethanechol chloride (Urecholine).
    D. Remind the patient to try the Valsalva maneuver.
    D. Remind the patient to try the Valsalva maneuver.

    Patients with lower motor neuron problems have a flaccid bladder, and increasing pressure on the bladder with the Valsalva maneuver may help the patient void.

    Because the bladder already holds 700 mL, the nurse should not wait for 2 more hours before taking action to empty the bladder.

    If the Valsalva maneuver is ineffective, straight catheterization or cholinergic medications such as Urecholine may be used to help empty the bladder.
    (this multiple choice question has been scrambled)
  29. The client is struggling with the use of eating utensils. With which member of the rehabilitation team does the rehabilitation nurse coordinate care for this client?

    A. Physiatrist
    B. Physical therapist
    C. Activity therapist
    D. Occupational therapist
    D. Occupational therapist

    Occupational therapists work to develop the client's fine motor skills used for activities of daily living (ADLs), such as those required for eating, maintaining hygiene, dressing, and driving.

    Physical therapists help the client achieve mobility (e.g., by facilitating ambulation and teaching the client to use a walker).
    (this multiple choice question has been scrambled)
  30. What roles does the rehabilitation nurse have in the rehabilitation team? (Select all that apply.)

    A. Coordinates holistic care
    B. Coordinates rehabilitation team activities
    C. Develops the client's fine motor skills
    D. Plans continuity of care for discharge
    E. Retrains clients with swallowing challenges
    A, B and D

    One of the roles of the rehabilitation nurse is to coordinate holistic care for the client.

    Occupational therapists work to develop the client's fine motor skills used for ADLs, such as those required for eating, maintaining hygiene, dressing, and driving.

    Speech-language pathologists evaluate and retrain clients with speech, language, or swallowing problems.
  31. The client is being discharged home. Which intervention provides the best assessment for home modification and helps diminish the client's anxiety?

    A. Discharge teaching
    B. Leave of absence visit
    C. Predischarge assessment
    D. Home visits by the case manager
    B. Leave of absence visit

    A method of assessing the client's home is through a brief home visit, also called a leave of absence (LOA) visit, before discharge.

    After discharge to home, various health care resources (e.g., physical therapy, home care nursing, vocational counseling) are available to the client with chronic illness and disability, but this is often too late for home modification.
    (this multiple choice question has been scrambled)
  32. The 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace after a fall. Which type of transfer technique is indicated for this client?

    A. Cane-assisted transfer
    B. Sliding board
    C. Bear hug technique
    D. Mechanical lift
    D. Mechanical lift

    Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method to move this client.

    Sliding boards are typically used for transferring quadriplegic clients.
    (this multiple choice question has been scrambled)
  33. The client is recovering from an accident that has rendered him a quadriplegic. Which psychosocial assessment nursing diagnosis does the rehabilitation nurse use for this client?

    A. Ineffective Coping related to situational crisis and/or inadequate time to prepare for stressor
    B. Risk for Impaired Skin Integrity related to altered sensation and/or altered nutritional state
    C. Constipation related to neurologic impairment
    D. Impaired Physical Mobility related to neuromuscular impairment, sensory-perceptual impairment, and/or pain
    A. Ineffective Coping related to situational crisis and/or inadequate time to prepare for stressor

    Constipation is a physical, not psychosocial, assessment diagnosis.
    (this multiple choice question has been scrambled)
  34. The client who is paraplegic resulting from a gunshot wound to the sixth thoracic vertebra exhibits incontinence that presents as sudden and gushing. When catheterized after an incontinence episode, urine remains in the bladder. Which bladder training technique is best for the nurse to promote for this client?

    A. Providing a high-fiber diet
    B. Valsalva and Cred' maneuvers
    C. Taking anticholinergic medication as prescribed
    D. Scheduling of intermittent catheterization
    D. Scheduling of intermittent catheterization

    Valsalva and Cred' maneuvers are best used for the client with a flaccid bladder.

    Cholinergics, not anticholinergics, are the medication of choice for the client with residual urine in the bladder.

    Intermittent catheterization may be used for disorders that involve a flaccid or spastic bladder.
    (this multiple choice question has been scrambled)

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