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...

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...

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)...

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...

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...

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...

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...

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)...

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)...

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)...

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...

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...

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)...

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...

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...

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 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...

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...

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...

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...

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)...

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...

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...

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:...

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...

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 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...

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...

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...

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...

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...

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...

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:...

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...

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...

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)...

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: ...

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...

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...

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...

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,...

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)...

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...

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...

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...

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...

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 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...

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)...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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...

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)...

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....

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...

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,...

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)...

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...

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...

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...

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...

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 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...

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...

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)...

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)...

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)...

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: ...

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...

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...

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...

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)...

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....

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...

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...

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:...

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...

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)...

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: ...

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)...

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...

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...

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...

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)...