ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 10 : Principles and Practices of Rehabilitation Questions
Question 1 of 5
A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
Correct Answer: D
Rationale: The nurse should also be aware of the patients medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the familys involvement in the patients ADLs. It is not normally necessary to teach the patient about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.
Question 2 of 5
An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs?
Correct Answer: A
Rationale: The nurses role is to provide an optimal learning environment that minimizes distractions. Describing the evidence base is not a priority, though nursing actions should indeed be evidence-based. Assistedliving facilities are not relevant to most patients. Absolute independence in ADLs is not an appropriate goal for every patient.
Question 3 of 5
You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care?
Correct Answer: B
Rationale: Patients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted-living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A healthcare aide is not needed by most patients.
Question 4 of 5
The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation?
Correct Answer: C
Rationale: Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulationwhether with brace, walker, cane, or crutchesthe patient must strengthen the muscles required.
Therefore, exercise is the foundation of preparation.
Question 5 of 5
A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use?
Correct Answer: D
Rationale: After sitting and standing balance is achieved, the patient is able to use parallel bars. The patient must be able to use the parallel bars before he can safely use devices like a cane, crutches, or a walker.