ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 10 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
A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing?
Correct Answer: B
Rationale: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the patient. Passive exercises are carried out by the therapist or the nurse without assistance from the patient. Resistive exercises are carried out by the patient working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.
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 nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care?
Correct Answer: B
Rationale: There is a growing trend toward independent living for patients who are severely disabled, either alone or in groups. The goal is integration into the community. The nurse would be sure to mention this fact when talking to a local community group. The nurse would not describe extended rehabilitation care, acute-care center treatment, or state institutions because these are not increasing in importance.
Question 5 of 5
A patient has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the patient is admitted to a rehabilitation facility?
Correct Answer: C
Rationale: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.