Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

Chapter 09: Chronic Illness and Rehabilitation
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE

1. The rehabilitation nurse describes a patient who is blind, works full time as a Spanish interpreter, and lives with his wife in a downtown apartment. How should the nurse classify this person?
a. Impaired
b. Disabled
c. Handicapped
d. Dependent

ANS: A
The blindness is an impairment of vision that does not inhibit the patient from performing his job or enjoying a normal life.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 178
OBJ: 1 (theory) TOP: Concepts of Rehabilitation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. A resident with advanced Parkinson disease stays in his wheelchair all day. He reports that he is too tired to walk and is fearful of falling. Which intervention to increase the patient’s mobility should the nurse add to the patient’s care plan?
a. Instruct the resident in crutch walking.
b. Assist the resident with ambulating in the hallway with a gait belt.
c. Encourage the resident to rock back and forth in his wheelchair to off-load weight.
d. Arrange for a walking cane.

ANS: B
Walking is the best exercise to prevent problems associated with immobility. The gait belt will make the resident more secure. Canes and crutches do not diminish the weakness or the fear of falling.

PTS: 1 DIF: Cognitive Level: Application REF: 185, Box 9-5
OBJ: 2 (theory) TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

3. The nurse is caring for an obese resident with a pressure ulcer on her coccyx. The patient frequently lies on her back because it is difficult to turn due to her weight. Which intervention most effectively encourages independence?
a. Instruct the staff turn the resident every 2 hours.
b. Turn the patient on her side and use pillows to stabilize her.
c. Arrange for short side rails to be used for positioning.
d. Arrange for a trapeze so the patient can assist with positioning.

ANS: D
The trapeze allows for self-positioning and is less confining than are bed rails. Turning the patient on her side or using short rails for positioning do not foster independence.

PTS: 1 DIF: Cognitive Level: Application REF: 187
OBJ: 2 (theory) TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

4. After assessing reddened heels on a bed-bound patient with a history of a stroke, which intervention should the nurse add to the care plan?
a. Massage heels briskly.
b. Apply socks to feet.
c. Swab heels with alcohol.
d. Elevate feet on pillows.

ANS: D
Elevation of the feet gets the weight off the heels and will allow them to heal. All other options are not helpful to damaged skin. Brisk massage may promote damage to the skin. Alcohol can be irritating and may further damage heel skin.

PTS: 1 DIF: Cognitive Level: Application REF: 181, Nursing Care Plan 9-1
OBJ: 2 (theory) TOP: Preventing Problems of Immobility
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

5. The nurse is educating a 70-year-old patient who just had a cast removed from a broken arm. The nurse should teach the patient about which potential effect of immobility related to casting?
a. Arthritis
b. Phlebitis
c. Frozen shoulder
d. Painful swelling

ANS: C
Immobility can cause loss of strength and flexibility in the older adult.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 180, Table 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Joint Stiffness
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

6. The nurse is caring for an 85-year-old patient who has been on bed rest for a fractured hip. The nurse finds that the patient is flushed, has a temperature of 100° F, a pulse of 100, and respiratory rate of 24. What assessment should the nurse perform next?
a. Obtain blood pressure (BP)
b. Auscultate breath sounds
c. Assess for abdominal distention
d. Measure amount of urinary output in the last hour

ANS: B
The initial assessments are the cardinal signs of pneumonia. The breath sounds should be assessed next to determine the presence of any adventitious breath sounds. BP will also need to be assessed, but the breath sounds are more important with the signs and symptoms present. Abdominal distention is indicative of a gastrointestinal problem. Amount of urinary output is important to an ongoing assessment but not a priority in the present circumstances.

PTS: 1 DIF: Cognitive Level: Analysis REF: 180, Table 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Hypostatic Pneumonia
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

7. The nurse is caring for a 76-year-old patient in a long-term care facility who sent his food tray back to the kitchen untouched for the second time today. Which intervention is most effective to increase nutrition?
a. Offer to feed the patient.
b. Ask the dietitian to talk with the patient about food preferences.
c. Offer the patient a high-protein drink.
d. Sit with the patient during meals.

ANS: C
Taking the high-energy drink meets the immediate challenge of inadequate nutritional intake. Referral to the dietitian and sitting with the patient may be helpful. Offering to feed from a rejected tray is not supportive.

PTS: 1 DIF: Cognitive Level: Analysis REF: 183
OBJ: 4 (theory) TOP: Effects of Immobility: Anorexia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance

8. The nurse assesses a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. Which is the best intervention to prevent further skin damage?
a. Cover the site with a transparent film dressing.
b. Apply warm compresses each shift.
c. Turn the patient every 2 hours.
d. Continue to monitor the area.

ANS: A
Since this appears to be a stage 1 pressure area, the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area. A warm compress is not warranted. This patient will need to be turned every hour. Monitoring of the area should continue but does not meet the immediate need.

PTS: 1 DIF: Cognitive Level: Analysis REF: 181, Nursing Care Plan 9-1
OBJ: 3 (theory) TOP: Effects of Immobility: Impaired Circulation
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

9. The LPN/LVN making care assignments to nursing assistants would not assign a patient who has which problem?
a. Manipulative behavior
b. An unstable condition
c. A draining wound
d. A communicable disease

ANS: B
Nursing assistants are not assigned to patients who have an unstable condition. Care of an unstable patient does not fall into the scope of practice of the unlicensed personnel.

PTS: 1 DIF: Cognitive Level: Comprehension
REF: 184, Assignment Considerations OBJ: 5 (theory) TOP: Assigning Personnel
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

10. Which statement describes the chief goal of a long-term care facility?
a. To offer restorative services
b. To promote individual independence
c. To facilitate achievement of complete autonomy
d. To manage medication protocols

ANS: B
Promotion of independence is the chief goal, not complete autonomy. Other options are services directed at achieving increased independence.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 187
OBJ: 4 (theory) TOP: Goal of Long-Term Care Facilities
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

11. The nurse educates the nursing assistant about the importance of locking the wheels of a wheelchair. Which statement indicates that the nursing assistant understands the nurse’s teaching?
a. “The locks supply a stable support for a patient to lift himself.”
b. “The locks keep patient in position at a table or bedside.”
c. “The locks help to prevent falls.”
d. “The locks keep the patient from moving himself.

ANS: C
Fall prevention is the purpose of locking the wheels of a wheelchair.

PTS: 1 DIF: Cognitive Level: Application REF: 185, Box 9-5
OBJ: 7 (theory) TOP: Fall Prevention
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

12. The long-term care facility nurse is discussing fall prevention measures with the charge nurse. Which replacement should the nurse suggest?
a. Replacing canes with 4 feet with a single-footed cane.
b. Replacing hard-soled shoes with soft-soled bedroom slippers.
c. Replacing area rugs with a nonslip pad.
d. Replacing plain carpet with a highly patterned carpet.

ANS: C
Loose area rugs should be replaced with nonslip carpets.

PTS: 1 DIF: Cognitive Level: Application REF: 185, Box 9-5
OBJ: 11 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. The nurse is instructing a family about chair selection for an older adult with Parkinson disease. Which information is most important for the nurse to include?
a. Choose a chair that is very wide to allow for position changes.
b. Choose a chair with sturdy arms to aid in rising.
c. Choose a chair that is low to the ground to prevent falls.
d. Choose a chair that is soft and deep for added comfort.

ANS: B
Sturdy arms assist in rising and sitting. Soft, low, and wide chairs cause a person to lean forward to rise and to “fall into” the chair to be seated.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 185, Box 9-5
OBJ: 10 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

14. The charge nurse instructs the nursing assistants about the policy concerning call lights. The nurse teaches that patients taking which type of medication require especially prompt call light attention?
a. Diuretics
b. Antibiotics
c. Proton pump inhibitors
d. Nonsteroidal anti-inflammatory drugs (NSAIDs )

ANS: A
People taking diuretics need to go to the bathroom frequently, and often urgently. Prompt attention to call lights will reduce the probability of the patient getting up unassisted. Diuretics may also cause orthostatic hypotension, which increases the risk for falling.

PTS: 1 DIF: Cognitive Level: Application REF: 185, Box 9-5
OBJ: 11 (clinical) TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. The nurse is caring for a resident who has a security device for safety purposes. What intervention should the nurse include in the plan of care?
a. Visually check the resident every hour.
b. Turn and reposition the resident every hour.
c. Assess condition of the skin every 4 hours.
d. Reassess the need for the security device every 4 to 8 hours.

ANS: D
The need for continuing the use of the security device must be assessed every 4 to 8 hours. The patient should be visually checked every 30 minutes, and turned and skin assessed every 2 hours.

PTS: 1 DIF: Cognitive Level: Application REF: 185, Box 9-5
OBJ: 11 (clinical) TOP: Use of Security Devices
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

16. When the confused resident pours his cereal in a cup and “drinks” it, how should the nurse best respond?
a. Put his cereal back in the bowl and hand the resident a spoon.
b. Discard the cup with his cereal and bring fresh cereal in a bowl.
c. Calmly instruct the resident that cereal is to be eaten from a bowl.
d. Do nothing to interrupt the behavior.

ANS: D
While this method of eating cereal is not typical, it is not harmful and allows the patient to be independent. The nurse should leave the resident alone to feed himself independently. Staff should refrain from doing what the resident can do for himself, so transferring his cereal to another container, discarding the cereal, or telling the patient that he cannot eat the cereal in a certain way is not appropriate.

PTS: 1 DIF: Cognitive Level: Application REF: 187
OBJ: 4 (theory) TOP: Long-Term Care Facility Goals: Autonomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity

17. The nurse is planning a group TV activity in a long-term care facility. The nurse should select a channel that offers which type of program?
a. Cartoons
b. Travel documentaries
c. Dramatic two-part mini-series
d. Opera performances

ANS: B
Travel documentaries are colorful and do not have a plot to follow. Cartoons are juvenile, opera does not have universal appeal, and the two-part drama would require long attention spans and good short-term memory.

PTS: 1 DIF: Cognitive Level: Application REF: 188
OBJ: 4 (theory) TOP: Long-Term Care Facility Goals: Autonomy
KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity

18. The nurse is seeking to motivate a frustrated patient who is learning to walk again after a stroke. Which intervention would be most effective?
a. Show short movies on ambulation techniques.
b. Observe the patient while in physical therapy.
c. Arrange a visit with another stroke victim who has learned to ambulate.
d. Encourage a 1-week break from therapy, which will help the resident come back refreshed.

ANS: C
Talking with someone who can truly understand the frustration is helpful. Showing a short movie on ambulation techniques may be an effective teaching tool, but it is not a motivational tool. Observing the resident is necessary but does not provide motivation. A 1-week break will interrupt progress that has been made, thus decreasing motivation.

PTS: 1 DIF: Cognitive Level: Application
REF: 189, Older Adult Care Points OBJ: 7 (theory)
TOP: Goals for Rehabilitation: Motivation
KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity

19. The nurse is caring for a disoriented resident. Which intervention is most appropriate for the nurse to include when planning care for this patient?
a. Ensure that activities are scheduled for the same time each day.
b. Change care assignments for assistive personnel frequently to prevent burnout.
c. Encourage autonomy by allowing the resident to choose clothes from the closet.
d. Administer sedatives to calm the patient.

ANS: A
Keeping a routine leads to less confusion. Changing assistive personnel care assignments frequently is confusing for the resident. Choosing clothing from an entire closet is overwhelming for the confused resident; rather, giving the resident a few items to choose from encourages autonomy without increasing confusion. Sedatives should not be given to treat confusion.

PTS: 1 DIF: Cognitive Level: Application REF: 186
OBJ: 4 (theory) TOP: Managing Confusion and Disorientation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity