Chapter 38: Rehabilitation Nursing My Nursing Test Banks

Chapter 38: Rehabilitation Nursing

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing what type of nursing?

a. Holistic nursing
b. Conscientious nursing
c. Rehabilitation nursing
d. Comprehensive nursing

ANS: C

Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1193

OBJ: 1 TOP: Rehabilitation KEY: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance

2.The nurse recognizes that the rehabilitation process involves the efforts of various disciplines. The focus of rehabilitation is to build on which area?

a. A persons losses
b. A persons long-term plans
c. A persons drives
d. A persons abilities

ANS: D

The underlying philosophy of rehabilitation is to focus on the abilities of the patient.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1193

OBJ:1TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

3.The nurse should tell a paraplegic that the rehabilitation experience will consist of:

a. relearning former skills.
b. learning to walk.
c. learning new skills to adapt to a different lifestyle.
d. developing muscle strength.

ANS: C

The type and the focus of rehabilitation are individualized to the patient, the injury, and abilities. Skills will be taught to enhance the patients adaptation to a new lifestyle.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1195

OBJ:3TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

4.The nurse who helps a patient with a disability rejoice in the acquisition of the smallest new skill is embracing which rehabilitation philosophy?

a. Resolving impairments
b. Removing disabilities
c. Increasing quality of life
d. Eliminating complications

ANS: C

A philosophy of rehabilitation is to increase the quality of life. Impairments may not be able to be resolved, disabilities may not be able to be completely removed, and complications may not be totally eliminated. However, with rehabilitation, the individual can learn to adjust to the new lifestyle.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1195

OBJ:1TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

5.A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation nurse, Im sick of this therapy! What is an occupational therapist going to do for me? Can she give me an occupation? What response by the nurse would be the most helpful?

a. No, but the occupational therapist can show you how to enjoy some recreational activities.
b. Yes, in a way. The occupational therapist provides training that strengthens muscles you can still control.
c. Maybe. The occupational therapist recommends adaptive equipment that will make you more independent.
d. No, the voc-rehab counselor helps with employment. The occupational therapist helps train you for improved communication skills.

ANS: C

The occupational therapist recommends adaptive equipment or helps in modifying skills to enhance independence.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1196, Table 38-1

OBJ:4TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

6.When caring for a patient with a disability, the rehabilitation nurse provides individual treatment to help the patient stay focused on which goals?

a. Returning to normal
b. Independence
c. Employment
d. Promotion of health

ANS: B

The focus on rehabilitation is on enabling the individual to move from a totally dependent state to a level of independence.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1197

OBJ:3TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

7.Following admission, how soon must a comprehension rehabilitation plan of care be implemented on a rehabilitation patient?

a. 12 hours
b. 24 hours
c. 3 days
d. 1 week

ANS: B

A comprehensive rehabilitation plan must be initiated within 24 hours of admission to the rehabilitation service. The results of the interdisciplinary assessment provide the basis for development of the plan of care. The team has 3 days from admission to review and revise the plan of care.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1195

OBJ:4TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

8.Which is a characteristic of the interdisciplinary approach to the rehabilitation team?

a. Each discipline makes its own goals for the patient.
b. There are clear boundaries between the disciplines.
c. There is a combination of expanded problem solving beyond the boundaries of the individual disciplines.
d. Cross-trained people are used who have functional ability in two or more disciplines.

ANS: C

In the interdisciplinary approach, the team collaborates on the goals for the patient. In the multidisciplinary rehabilitation team approach, each discipline makes its own goals for the patient and there are clear boundaries between the disciplines. The transdisciplinary rehabilitation team is characterized by the blurring of boundaries between disciplines and the cross-training and flexibility to reduce a duplication of efforts.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1196

OBJ:4TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

9.When planning care for children, the nurse uses a concept that recognizes the pivotal role of the family in the lives of children with disabilities or other chronic conditions. What is this philosophy called?

a. Child-centered care
b. Systems-centered care
c. Family-centered care
d. Individual-centered care

ANS: C

Family-centered care is an evolving concept that uses the family as equal partners in the rehabilitation process.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1198

OBJ:6TOP:Rehabilitation

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

10.What is the primary difference between the rehabilitation of children and the rehabilitation of adults?

a. Level of disability
b. Body part involved
c. Degree of disability
d. Developmental potential

ANS: D

The primary difference between rehabilitation of children and rehabilitation of adults is the developmental potential of the child.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1206

OBJ:10TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

11.The acquisition of adaptive skills and behaviors by an individual who has been disabled since birth refers to:

a. training.
b. education.
c. development.
d. habilitation.

ANS: D

Habilitation refers to developing skills and behaviors in people who did not have the skills originally. Children who are disabled from birth have no skills to relearn and are habilitated rather than rehabilitated.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1206

OBJ: 10 TOP: Habilitation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

12.The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitation nurse must assess not only the debilitating factors of disease but also which other factor?

a. Advancing age
b. Reduced ability to learn
c. Limited energy
d. Eroded interest level

ANS: A

Gerontological rehabilitation nursing focuses on the unique requirements of older adult rehabilitation. The elderly, with their potential physical limitations, require specialized care.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1207

OBJ:10TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

13.The nurse explains that the main roles of the gerontological rehabilitation nurse are to provide rehabilitative care and what other role?

a. Provide restoration
b. Teach prevention
c. Teach adaptive skills
d. Provide positive reinforcement

ANS: B

Teaching prevention is the dual role of the geriatric rehabilitation nurse. Restoration, adaptive skills, and positive reinforcements are all part of providing rehabilitative care.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1207

OBJ:10TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

14.What should the nurse do to reduce the incidence of postural hypotension in a patient with a spinal cord injury?

a. Monitor diastolic blood pressure closely
b. Encourage the patient to remain in the bed
c. Raise the head of the bed for 15 to 20 minutes before transfer to a wheelchair
d. Encourage adequate intake of fluids to expand fluid volume

ANS: C

Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. It is important to check the patients blood pressure, but it will not reduce the incidence of postural hypotension. It is important to encourage the patient to get out of bed. Postural hypotension is related to a pooling of blood in the lower extremities and is not related to a fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1202

OBJ:7TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

15.The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering which condition?

a. Paresis
b. Heterotopic ossification
c. Postural hypotension
d. Autonomic dysreflexia

ANS: D

Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1204

OBJ:7TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16.The nurse instructs the mother of a 5-year-old who sustained a mild brain injury that although all neurologic evaluations are normal, her child may exhibit postconcussive syndrome. What are common characteristics of this syndrome?

a. Convulsions and high fever
b. Irritability and memory deficits
c. Muscular twitching and muscle pain
d. Paresis of limbs and fatigue

ANS: B

Mild brain injury is characterized by brief or no loss of consciousness. This type constitutes the majority of head injuries. Neurologic examinations are often normal. Postconcussive syndrome can persist for months, years, or indefinitely. Signs and symptoms include fatigue, headache, vertigo, lethargy, irritability, personality changes, cognitive deficits, decreased information processing speed and memory, understanding, learning, and perceptual difficulties.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1204

OBJ:7TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17.When changing the position of a patient with a spinal cord injury at T4, the nurse should recognize that what symptom is an indication of an episode of autonomic dysreflexia?

a. Nausea
b. Pallor
c. Goose bumps
d. Dizziness

ANS: C

Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets. Other symptoms may include diaphoresis, shivering, goose bumps, flushing of the skin, and a severe pounding headache.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1204

OBJ:7TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

18.When assessing a patient with a traumatic brain injury, the nurse notes that his memory is improving. The nurse should explain to the family that what other symptom may occur with memory improvement?

a. Decrease in learning ability
b. Depression
c. Anger
d. Increased concentration

ANS: B

Generally, the more memory improves in a patient with a brain injury, the more the patient becomes depressed.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1205

OBJ:7TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

19.When caring for a 32-year-old Hispanic male who has become disabled, on what should the rehabilitation team base the priority of treatment goals?

a. Difficulty of the language barrier
b. Cultural significance of the disability
c. Depth of the patients support system
d. Attitude toward rehabilitation

ANS: B

Culture defines the significance of disease and disability. Although all of the options must be addressed, the significance of the disability has highest priority.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1199

OBJ:2TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

20.What is the best way to define a handicap?

a. Any loss of function
b. A disability that interferes with ones normal functioning
c. Any loss of ability to perform activities of daily living
d. An irreversible lifelong impairment

ANS: B

A handicap is a disadvantage for a given individual from an impairment that limits his or her role performance. A particular handicap for one person might not pose any handicap for another with the same disability. An impairment is a loss of function. A functional limitation is a disability that interferes with ones normal functioning. A chronic illness is an irreversible lifelong impairment.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1194

OBJ:1TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

21.What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury?

a. Massage the patients legs daily
b. Perform passive range-of-motion exercises
c. Encourage frequent warm baths
d. Allow the patients legs to dangle for a period of 10 minutes several times a day

ANS: B

DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1204

OBJ:5TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

22.When the nurse observes a patient experiencing a severe episode of autonomic dysreflexia, what should be the initial intervention?

a. Locate the cause of irritation
b. Assess the blood pressure
c. Cover the patient with several blankets
d. Raise the head of the bed to a high Fowler position

ANS: D

The head of the bed should be raised immediately. Raising the head of the bed will reduce the blood pressure. Finding the cause of the episode is secondary to preventing the possibility of a stroke from the hypertension.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1204

OBJ:5TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

23.When speaking to a group of high school students, the rehabilitation nurse states that spinal cord injuries resulting in paralysis occur mainly as the result of traumatic accidents in which group of individuals?

a. Middle-aged men
b. Older adult females
c. Young males
d. Young females

ANS: C

Individuals paralyzed by spinal cord injuries are primarily young males.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201

OBJ:2TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

24.The spinal cord injury patient has paralysis of all extremities and bowel and bladder disturbance. The nurse recognizes the injury as most likely occurring at what vertebral level?

a. C1 to C2
b. C3 to C4
c. C2 to C7
d. C4 to C7

ANS: C

The vertebral level of injury for a cervical cord is C2 to C7 if the patient has paralysis of all extremities and trunk, and has lost control of bowel and bladder function.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1201

OBJ:2TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

25.The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. What intervention would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury?

a. Encouraging large fluid intake
b. Seeking spiritual support from a higher being
c. Using the spouse as a support system
d. Positioning to maintain alignment

ANS: D

Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1197

OBJ:5TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

26.What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?

a. Loud sound
b. Distended bladder
c. Leg cramp
d. Sudden chilling

ANS: B

Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure ulcers, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1204

OBJ:5TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

27.The rehabilitation nurse stresses to the family of a patient with a brain injury that difficult and painful rehabilitation will probably be required for what length of time?

a. 1 to 2 years
b. 2 to 4 years
c. 5 to 10 years
d. 6 to 12 years

ANS: C

Most brain-related disabilities, including physical, cognitive, and psychosocial difficulties, call for at least 5 to 10 years of difficult and painful rehabilitation; many require lifelong treatment and attention.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1204

OBJ:7TOP:Rehabilitation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

28.The rehabilitation nurse recognizes that the majority of patients with head injuries show no abnormal neurologic findings and experience no loss of consciousness. How should the nurse categorize this type of brain injury?

a. Mild
b. Moderate
c. Severe
d. Catastrophic

ANS: A

Mild brain injury is characterized by no loss of consciousness and no abnormal neurologic findings.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1204

OBJ:2TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

29.A 33-year-old patient with a spinal cord injury says to the nurse, Ive let my family down. I dont know what to do. What would be the best response by the nurse?

a. After your rehabilitation starts, youll feel better.
b. You should be grateful you are alive.
c. What does this injury mean to you?
d. Technological advances are changing the future for spinal cord injury victims.

ANS: C

The patient should be encouraged to express his or her feelings about the disability.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1201

OBJ:5TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychological Integrity

30.The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a brain injury. Which assessment data would support the diagnosis?

a. Frequently becomes violent
b. Becomes easily fatigued
c. Is depressed
d. Cannot add three numbers in his head

ANS: D

Impaired cognition includes problems in thinking, impaired concentration, and impaired information processing.

PTS: 1 DIF: Cognitive Level: Analysis REF: Pages 1204-1205

OBJ:5TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

31.The patient with a brain injury is beginning to regain memory. The nurse explains to the family that what will most likely occur?

a. The patient will become less combative.
b. The patient will become angrier.
c. The patient will become more depressed.
d. The patient will wish to retire.

ANS: C

Generally, the more the memory improves, the more the patient becomes depressed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1205

OBJ:7TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

32.The nurse explains that the Americans with Disabilities Act of 1990 defines a person as disabled if which criteria are met? (Select all that apply.)

a. The person has a physical or mental impairment.
b. The person is limited in at least one major life activity.
c. The person has a medical record of the impairment.
d. The person is unemployed.
e. The person needs assistance in completion of ADLs.

ANS: A, B, C

The definition is that a disabled person may have a physical or mental impairment that limits the person in one or more  major life activities and has a medical record of that disability.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201

OBJ:2TOP:Americans with Disabilities Act (ADA)

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

33.The nurse is caring for a victim of post-traumatic stress syndrome. The nurse identifies which techniques as examples of therapeutic communication? (Select all that apply.)

a. Listening
b. Reframing
c. Characterizing
d. Normalizing responses
e. Working to develop trust

ANS: A, B, D, E

The techniques of therapeutic communication that are important to use with the PTSD patient are listening, reframing, normalizing responses, and working to develop trust.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1201

OBJ: 9 TOP: PTSD KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

COMPLETION

34.The rehabilitation nurse assesses localized edema around the knee of a patient with paraplegia. The nurse suspects that this is the first sign of __________ _____________.

ANS:

heterotopic ossification

Heterotopic ossification is a bony growth in joints of spinal cord injury patients below the injury that ultimately limits range of motion.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1204

OBJ:7TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

35.A child who was struck by a car and suffered a closed head injury was unconscious for 24 hours before waking. The nurse recognizes this as a _______ brain injury.

ANS:

moderate

A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury.

PTS: 1 DIF: Cognitive Level: Application | Cognitive Level: Comprehension

REFage 1204OBJ:7TOP:Rehabilitation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

36.The nurse who assesses for cultural influences, values cultural diversity, and incorporates cultural knowledge in practice is said to be ____________ _____________.

ANS:

culturally competent

A culturally competent nurse includes knowledge of cultural values and influences in their nursing practice.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1199

OBJ: 5 TOP: Culture KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion

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