Test 4 (Ch 39)

Question 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

Answer 1

ANS: C

Question 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 person’s losses
b. A person’s long-term plans
c. A person’s drives
d. A person’s abilities

Answer 2

ANS: D

Question 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.

Answer 3

ANS: C

Question 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

Answer 4

ANS: C

Question 5

A patient with quadriplegia resulting from a spinal cord injury says to the rehabilitation nurse, “I’m 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 mosthelpful?
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.”

Answer 5

ANS: C

Question 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

Answer 6

ANS: B

Question 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

Answer 7

ANS: B

Question 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.

Answer 8

ANS: C

Question 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

Answer 9

ANS: C

Question 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

Answer 10

ANS: D

Question 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.

Answer 11

ANS: D

Question 12

The nurse who is engaged in gerontological rehabilitation nursing has a dual challenge. The gerontological rehabilitatio n 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

Answer 12

ANS: A

Question 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.

Answer 13

ANS: B

Question 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.

Answer 14

ANS: C

Question 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

Answer 15

ANS: D

Question 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

Answer 16

ANS: B

Question 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

Answer 17

ANS: C

Question 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

Answer 18

ANS: B

Question 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 patient’s support system
d. Attitude toward rehabilitation

Answer 19

ANS: B

Question 20

What is the best way to define a handicap?
a. Any loss of function
b. A disability that interferes with one’s normal functioning
c. Any loss of ability to perform activities of daily living
d. An irreversible lifelong impairment

Answer 20

ANS: B

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

Answer 21

ANS: B

Question 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’s position.

Answer 22

ANS: D

Question 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

Answer 23

ANS: C

Question 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

Answer 24

ANS: C

Question 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

Answer 25

ANS: D

Question 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

Answer 26

ANS: B

Question 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

Answer 27

ANS: C

Question 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

Answer 28

ANS: A

Question 29

A 33-year-old patient with a spinal cord injury says to the nurse, “I’ve let my family down. I don’t know what to do.” What would be the best response by the nurse?
a. “After your rehabilitation starts, you’ll 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.”

Answer 29

ANS: C

Question 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.

Answer 30

ANS: D

Question 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.

Answer 31

ANS: C