A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care?

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care? 

a) Having the client shift his or her weight every hour
b) Massaging any reddened areas of the skin
c) Placing the client in a semi-reclining position
d) Lubricating the skin with a non-irritating lotion

Answer: D

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions?

a) 45 degree flexion
b) 15 degree flexion
c) 25 degree flexion
d) 0 degree flexion

Answer: C

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

A spinal cord injury patient has no awareness of the need to void. This type of incontinence is termed

a) toilet incontinence.
b) reflex (neurogenic) incontinence.
c) functional incontinence.
d) stress incontinence.

Answer: B

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension?

A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension? 

a) Nausea
b) Flushing
c) Dry skin
d) Bradycardia

Answer: A

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first?

A patient is being taught to go down stairs using a cane. The nurse would instruct the patient to do which of the following first? 

a) Place the cane on the lower step.
b) Step down with the affected leg.
c) Step down with the unaffected leg.
d) Place cane and affected leg on step simultaneously.

Answer: C

Which intervention has the highest priority when providing skin care to a bedridden client?

Which intervention has the highest priority when providing skin care to a bedridden client?

a) Changing the client's position frequently
b) Keeping the skin clean and dry without using harsh soaps
c) Rubbing moisturizing lotion over the pressure areas
d) Gently massaging the skin around the pressure areas

Answer: B

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?

A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following? 

a) Thumb opposition
b) Supination
c) Wrist flexion
d) Ulnar deviation

Answer: D

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply.

a) Constipation
b) Edema
c) Sensory overload
d) Diaphoresis
e) Anemia

Answer: B, E & D.

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

Which type of scale is used for systematic assessment and quantification of a patient's risk for pressure ulcer?

a) Barthel index
b) Braden scale
c) FIM
d) PULSES profile

Answer: B

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length?

A patient who is 5 feet 10 inches tall is being measured for crutches. The nurse determines which crutches as being the appropriate length? 

a) 66 inches
b) 60 inches
c) 54 inches
d) 48 inches

Answer: C

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

a) Stage I
b) Stage III
c) Deep tissue injury
d) Stage IV
e) Stage II

Answer: B & D.

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?

A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?

a) Fowler's
b) Prone
c) Lateral
d) Recumbent

Answer: D

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position? 

a) Side-lying
b) Prone
c) Semi-Fowler's
d) Supine

Answer: B

The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene?

The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene? 

a) Client keeps the cane fairly close to the body when ambulating.
b) Client bears down on the cane when he begins to swing the unaffected leg.
c) Client advances the cane at the same time he moves the affected leg forward.
d) Client moves the arm and leg on the same side together at the same time.

Answer: D

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

a) "Keep feet 12? (30 cm) apart to provide stability and a wide base of support."
b) "Use the axillae to help carry the weight."
c) "Take long strides to maintain maximum mobility."
d) "All weight should be on the hands."

Answer: D

The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?

The nurse is helping a patient who experiences frequent constipation select his meal choices for the day. Which of the following should the nurse encourage the patient to order?

a) Applesauce
b) Bananas
c) Bran cereal
d) Pop tart

Answer: C

The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?

The nurse is completing an initial assessment on an elderly patient. When asked about her urinary patterns, the patient states that she can "never get to the bathroom in time." The nurse documents this as which of the following?

a) Functional incontinence
b) Urge incontinence
c) Reflex incontinence
d) Stress incontinence

Answer: A

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?

A client with a walker is being discharged from the orthopedic unit to home. The nurse must teach the client how to use a walker properly. Which explanation demonstrates safe walker use?

a) Adjusting the height of the walker so the arms aren't bent when the hands rest on the walker grips
b) Moving the walker, stepping with the affected leg, then stepping with the unaffected leg
c) Using the walker for support while rising from a chair
d) Moving the walker, stepping with the unaffected leg, then stepping with the affected leg

Answer: B

A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage?

A nurse is developing a plan of care for a patient experiencing urinary incontinence and identifies a nursing diagnosis of risk for infection related to urinary incontinence and inadequate bladder emptying. Which of the following would the nurse most likely include as an appropriate fluid to encourage? 

a) Carbonated cola
b) Cranberry juice
c) Tomato juice
d) Milk shakes

Answer: B

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

a) Hyperextending the client's legs
b) Performing shoulder range-of-motion (ROM) exercises
c) Applying knee splints
d) Elevating the foot of the bed

Answer: C

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? 

a) Tissue perfusion
b) Drainage
c) Skin color
d) Moisture

Answer: D

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following? 

a) Contracts the buttocks together for a count of five
b) Lifting the body off the bed while holding on to a trapeze
c) Raises the body by pushing the hands against the chair seat
d) Pushes the popliteal area against the mattress while raising the heel

Answer: D

The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following timeframes?

The nurse is performing a skin assessment on a bedbound patient who was positioned in a semi-Fowler's position. The nurse notices erythema over the sacrum and repositions the patient to a left recumbent position. The nurse anticipates resolution of the erythema will occur in less than which of the following timeframes? 

a) 15 minutes
b) 45 minutes
c) 1 hour
d) 30 minutes

Answer: C

Half of all spinal cord injuries are related to

Half of all spinal cord injuries are related to

a) work-related injuries.
b) substance abuse.
c) motorcycle accidents.
d) genetic predisposition.

Answer: B

Students are reviewing information about rehabilitation and brain and spinal cord injuries. They demonstrate understanding of the information when they identify which of the following as being responsible for approximately one-half of all traumatic brain injuries?

Students are reviewing information about rehabilitation and brain and spinal cord injuries. They demonstrate understanding of the information when they identify which of the following as being responsible for approximately one-half of all traumatic brain injuries?

a) genetic predisposition
b) work-related injuries
c) motorcycle accidents
d) substance abuse

Answer: D

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power?

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power? 

a) Passive exercises
b) Isometric exercises
c) Active exercises
d) Resistive exercises

Answer: D

The nurse is creating a bowel evacuation program for a paraplegic patient. When should the nurse plan for administration of a suppository?

The nurse is creating a bowel evacuation program for a paraplegic patient. When should the nurse plan for administration of a suppository?

a) 1 hour before dinner
b) Right before bed
c) Just before breakfast
d) 30 minutes after lunch

Answer: C

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? 

a) Patient
b) Nurse
c) Physical therapist
d) Physician

Answer: A

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

After sustaining a stroke, a client is transferred to the rehabilitation unit. The medical-surgical nurse reviews the client's residual neurological deficits with the rehabilitation nurse. Which neurological deficit places the client at risk for skin breakdown?

a) Right-sided visual deficit and dysarthria
b) Constipation and lower extremity weakness
c) Incontinence and right-sided hemiparesis
d) Dysarthria and left-sided visual deficit

Answer: C

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

a) Culture
b) Incision and drainage
c) Irrigation
d) Debridement

Answer: D

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest?

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? 

a) Avoid seeking help from others.
b) Group any heavy work to be done at the same time.
c) Emphasize areas of strengths.
d) Stop any activity once fatigue occurs.

Answer: C

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? 

a) PULSES profile
b) Functional Independence Measure (FIMTM)
c) Patient Evaluation Conference System
d) Barthel Index

Answer: B

The initial sign of skin pressure is erythema, which normally resolves in less than

The initial sign of skin pressure is erythema, which normally resolves in less than

a) 1 hour.
b) 30 minutes.
c) 15 minutes.
d) 45 minutes.

Answer: A

The nurse is working with the physical therapist to create a multidisciplinary plan of care for a patient in a rehabilitation unit. The therapist suggests that the patient would benefit from the use of light weights during shoulder exercises. The nurse incorporates this onto the plan of care as which of the following types of exercise?

The nurse is working with the physical therapist to create a multidisciplinary plan of care for a patient in a rehabilitation unit. The therapist suggests that the patient would benefit from the use of light weights during shoulder exercises. The nurse incorporates this onto the plan of care as which of the following types of exercise?

a) Active-assistance
b) Resistive
c) Passive
d) Isometric

Answer: B

A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize?

A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize? 

a) Keeping the catheter inserted for at least 1 hour
b) Following a regular emptying schedule
c) Using bladder distention to signal need for insertion
d) Maintaining sterility of the equipment

Answer: B

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?

a) Air-fluidized surface
b) Low-air-loss surface
c) Static support surface
d) Alternating pressure surface

Answer: A

Rotation of the forearm so that the palm of the hand is down is termed

Rotation of the forearm so that the palm of the hand is down is termed

a) supination.
b) inversion.
c) pronation.
d) eversion.

Answer: C

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following? 

a) Client expereinces a strong perceived urge to void.
b) Client lacks the sensory awareness about the need to void.
c) Client leaks urine when coughing or sneezing.
d) Client does not reach the toilet before experiencing voiding.

Answer: D

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers? 

a) Repositioning the patient about once a shift
b) Lifting rather than sliding the patient when repositioning her
c) Using a static support device on the patient's bed
d) Lubricating the skin with a non-irritating lotion

Answer: A

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage? 

a) Stage IV
b) Stage I
c) Stage II
d) Stage III

Answer: D

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?

A nursing assistant tells the nurse that a client with paraplegia has an area of skin breakdown on his left calf. When the nurse assesses the client, he is sitting on a cushion in a wheelchair and wearing specialty boots. The nurse notes a circular wound 2 cm × 2 cm × 0.25 cm on the posterior aspect of the calf. What most likely caused the client's skin breakdown?

a) Leg rest of the wheelchair
b) Specialty boots
c) Sitting in the wheelchair for long periods of time
d) Absence of sensation in the lower extremities and immobility

Answer: B

A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?

A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility? 

a) Diminished dermal collagen
b) Enhanced perception of sensations
c) Increased moisture level
d) Slowed peristaltic activity

Answer: A

Half of all spinal cord injuries are related to which of the following?

Half of all spinal cord injuries are related to which of the following?

a) Substance abuse
b) Genetic predisposition
c) Work-related injuries
d) Motorcycle accidents

Answer: A

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

a) reduce the client's fluid intake.
b) encourage the client to use a footboard.
c) perform passive range-of-motion (ROM) exercises.
d) turn him frequently.

Answer: D

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?

a) A wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue
b) A wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed
c) A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance
d) A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue

Answer: C

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:

a) do nothing; the client's skin is intact.
b) give the client a donut ring to reduce pressure on the affected area.
c) contact the client's family.
d) document the condition of the client's skin.

Answer: D

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next?

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next? 

a) Have the patient lie back down.
b) Encourage the patient to take deep breaths.
c) Have the patient stand up immediately.
d) Obtain a transfer board to ease the change.

Answer: A

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers?

a) 4.0 g/mL
b) 3.1 g/mL
c) 2.5 g/mL
d) 3.5 g/mL

Answer: C

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?

A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates effective teaching?

a) "My foot should feel cold."
b) "I'll eat plenty of fruits and vegetables."
c) "I'll make sure that the bandage is wrapped tightly."
d) "I'll limit my intake of protein."

Answer: B

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

A nurse is assisting a client with range-of-motion exercises. The nurse moves the client's leg out and away from the midline of the body. What movement does the nurse document?

a) Supination
b) Adduction
c) Pronation
d) Abduction

Answer: D

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time? 

a) After breakfast
b) Upon arising
c) Before bed
d) Around lunchtime

Answer: A

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description?

A nurse is describing the concept of habilitation to a group of families who have members in need of these services. Which of the following statements would the nurse include in this description? 

a) "Habilitation focuses on the person's abilities."
b) "Habilitation is primarily geared to those who can achieve independence."
c) "Habilitation negates the need for assistive devices."
d) "Habilitation begins once the patient is ready for discharge."

Answer: A

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to:

A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to:

a) prevent edema.
b) distribute weight away from the involved side.
c) prevent leaning.
d) maintain stride length.

Answer: B

The nurse is evaluating the lab values of a patient whose nursing diagnosis is "risk for impaired skin integrity." Which of the following lab values places the patient at greatest risk?

The nurse is evaluating the lab values of a patient whose nursing diagnosis is "risk for impaired skin integrity." Which of the following lab values places the patient at greatest risk?

a) Hematocrit: 43.5
b) Albumen: 1.5 g/dL
c) Hemoglobin: 10.5
d) Potassium: 3.0

Answer: B

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

a) Stage IV pressure ulcer
b) Stage I pressure ulcer
c) Stage III pressure ulcer
d) Stage II pressure ulcer

Answer: D

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply. 

a) Eating
b) Bathing
c) Cleaning
d) Toileting
e) Cooking

Answer: A, D & B.

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

a) Attaching braces or splints to each foot and leg
b) Crossing the client's ankles every 2 hours
c) Putting slippers on the client's feet
d) Placing hand rolls on the balls of each foot

Answer: A

The nurse working on a rehabilitation unit rotates a patient's forearm so that the palm of the hand is facing down. The nurse documents this movement as which of the following?

The nurse working on a rehabilitation unit rotates a patient's forearm so that the palm of the hand is facing down. The nurse documents this movement as which of the following?

a) Spination
b) Eversion
c) Pronation
d) Inversion

Answer: C

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement? 

a) Uses the handrail on one side to go down the stairs
b) Keeps the head erect while combing the hair
c) Lifts one leg by raising it off the ground
d) Holds onto the furniture when walking in the house

Answer: D

To help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use which of the following?

To help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be to use which of the following?

a) Pillows under the lower legs
b) A hip-abductor pillow
c) A trochanter roll extending from the crest of the ilium to the midthigh
d) A footboard

Answer: C

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area? 

a) Scapula
b) Ischial tuberosity
c) Lateral malleous
d) Greater trochanter

Answer: B

A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following? 

a) Opposition
b) Dorsiflexion
c) Adduction
d) Pronation

Answer: A

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue?

a) Stage III
b) Stage II
c) Stage I
d) Stage IV

Answer: A

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient?

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient?

a) Potassium
b) Calcium
c) Protein
d) Phosphorous

Answer: C

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues?

Through which of the following activities does the patient learn to consciously contract excretory sphincters and control voiding cues?

a) Kegel exercises
b) Bladder training
c) Habit training
d) Biofeedback

Answer: D

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

a) advance both legs.
b) advance the affected leg.
c) advance the unaffected leg.
d) advance both crutches.

Answer: D

The nurse assessing a patient on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain on which of the following movements?

The nurse assessing a patient on a rehabilitation units notices that the patient experiences pain when his right arm is moved away from the midline of his body. The nurse documents pain on which of the following movements?

a) Adduction
b) Abduction
c) Extension
d) Flexion

Answer: B

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

Which disciplines should be consulted when caring for a client with a stage III heel ulcer?

a) Plastic surgery and cardiology
b) Physical therapy and respiratory therapy
c) Nutrition support and orthotics
d) Occupational therapy and infectious disease

Answer: C

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

a) Turning the client every 2 hours and providing a low-air-loss mattress
b) Bathing and feeding the client to decrease energy expenditure
c) Raising the head of the bed to maximize the client's lung inflation
d) Decreasing fluid intake to ease dependent edema

Answer: A

Serum albumin is an indicator of which type of deficiency?

Serum albumin is an indicator of which type of deficiency?

a) Protein
b) Calcium
c) Potassium
d) Phosphorous

Answer: A

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address? 

a) Bathing
b) Grooming
c) Cooking
d) Dressing

Answer: C

The nurse is reading the previous shift's documentation of an open area on the patient's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the patient's sacrum will reveal a pressure ulcer in which of the following stages?

The nurse is reading the previous shift's documentation of an open area on the patient's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the patient's sacrum will reveal a pressure ulcer in which of the following stages?

a) Stage I
b) Stage III
c) Stage II
d) Stage IV

Answer: C

Which nursing intervention can help a client maintain healthy skin?

Which nursing intervention can help a client maintain healthy skin?

a) Avoiding bathing the client with mild soap
b) Keeping the client well hydrated
c) Recommending wearing tight-fitting clothes in hot weather
d) Removing adhesive tape quickly from the skin

Answer: B

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following? 

a) Stress incontinence
b) Urge incontinence
c) Functional incontinence
d) Reflex incontinence

Answer: A

To prevent footdrop, what is the best way for the nurse to position the patient?

To prevent footdrop, what is the best way for the nurse to position the patient?

a) In a sitting position with legs hanging off the side of the bed
b) In a side-lying position
c) To keep the feet at right angles to the leg
d) In a semisitting position in bed

Answer: C

Which stage of pressure ulcer is considered a partial-thickness wound?

Which stage of pressure ulcer is considered a partial-thickness wound?

a) Stage I
b) Stage III
c) Stage IV
d) Stage II

Answer: D

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

a) Whether the client drives a car with a stick shift
b) Whether pets are present in the home
c) Whether the client parks his car on the street
d) Whether the client needs to navigate stairs routinely at home

Answer: D

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair?

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? 

a) Water
b) Vitamin C
c) Protein
d) Zinc sulfate

Answer: C

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

a) Trochanter roll
b) Protective boots
c) Range-of-motion exercises
d) Pillow between the legs

Answer: A

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is

A type of therapeutic exercise performed by the patient where the muscle contracts and relaxes is

a) isometric.
b) passive.
c) active-assistive.
d) resistive.

Answer: A

A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?

A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait? 

a) Swing-to
b) 3-point
c) 4-point
d) Swing-through

Answer: D

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:

a) stress incontinence.
b) total incontinence.
c) reflex incontinence.
d) functional incontinence.

Answer: A

A patient who has experienced a stroke is learning to use a cane to ambulate. The patient has left-sided weakness. After teaching the patient about using the cane, the nurse determines that the patient has understood the instructions when stating that using the cane on the right is done for which purpose?

A patient who has experienced a stroke is learning to use a cane to ambulate. The patient has left-sided weakness. After teaching the patient about using the cane, the nurse determines that the patient has understood the instructions when stating that using the cane on the right is done for which purpose? 

a) To distribute weight away from the affected side
b) To reduce the risk of edema
c) To prevent leaning to one side
d) To promote a long stride length

Answer: A

Which therapeutic exercise is done by the nurse without assistance from the patient?

Which therapeutic exercise is done by the nurse without assistance from the patient?

a) Isometric
b) Passive
c) Resistive
d) Active

Answer: B

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

a) A loss of sexual functioning correlates with a loss of sexual feeling.
b) Priority setting is helpful in dealing with the impact of the disability.
c) Fatigue primarily results from physical demands.
d) Most care tasks required after discharge focus on the physical care.

Answer: B

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

During which stage of pressure ulcer development does the ulcer extend into the underlying structures, including the muscle and possibly the bone?

a) Stage II
b) Stage I
c) Stage IV
d) Stage III

Answer: C

Which of the following terms means movement away from the midline of the body?

Which of the following terms means movement away from the midline of the body?

a) Flexion
b) Abduction
c) Extension
d) Adduction

Answer: B

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective? 

a) "I should make sure my underarms are supported by the tops of the crutches."
b) "I need to learn to use one type of gait for getting around."
c) "I need to allow my arms and hands to support my body weight."
d) "I need to position the crutches even with my heels when standing."

Answer: C

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

a) Vigorously massage lotion over bony prominences.
b) Develop a written, individual turning schedule.
c) Turn and reposition the client at least once every 8 hours.
d) Slide the client, rather than lifting, when turning.

Answer: B

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing? 

a) Vitamin C
b) Calcium
c) Vitamin D
d) Vitamin E

Answer: A

A nurse is caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment?

A nurse is caring for a patient who is documented to have orthostatic hypotension. The nurse anticipates finding which of the following symptoms upon assessment?

a) Dizziness
b) Dry skin
c) Hypertension
d) Bradycardia

Answer: A

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased?

Which type of incontinence is associated with weakened perineal muscles that permit the leakage of urine when intra-abdominal pressure is increased?

a) Urge incontinence
b) Stress incontinence
c) Reflex (neurogenic) incontinence
d) Functional incontinence

Answer: B