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
The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area?
Correct Answer: C
Rationale: Full inspection of the patients skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.
Question 2 of 5
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
Correct Answer: C
Rationale: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than3 \mathrm{~g}/\mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.
Question 3 of 5
A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?
Correct Answer: A
Rationale: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void.
Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.
Question 4 of 5
A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient?
Correct Answer: C
Rationale: For cognitively intact women who experience stress incontinence, the nurse should instruct the patient to perform Kegel exercises four to six times per day to strengthen the pubococcygeus muscle. Keeping a record of when the incontinence occurs or accepting incontinence as part of aging are incorrect answers because they are of no value in treating stress incontinence. Women with stress incontinence do not need clean intermittent catheterization. Protective undergarments hide the effects of urinary incontinence but they do not resolve the problem.
Question 5 of 5
While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?
Correct Answer: B
Rationale: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this patient. The other listed diagnoses are not directly suggested by the noted assessment findings.