Chapter 10: Principles and Practices of Rehabilitation
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 13th Edition
MULTIPLE CHOICE
1. The nurse is providing care for an older adult man whose diagnosis of
dementia has recently led to urinary incontinence. When planning this
patient's care, what intervention should the nurse avoid?
A) Scheduled toileting
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads
ANS: B
Indwelling catheters are avoided if at all possible because of the high incidence
of urinary tract infections with their use. Intermittent self-catheterization is an
appropriate alternative for managing reflex incontinence, urinary retention, and
overflow incontinence related to an overdistended bladder. External catheters
(condom catheters) and leg bags to collect spontaneous voiding are useful for
male patients with reflex or total incontinence. Incontinence pads should be
used as a last resort because they only manage, rather than solve, the
incontinence.
2. You are the nurse caring for a female patient who developed a pressure ulcer
as a result of decreased mobility. The nurse on the shift before you has
provided patient teaching about pressure ulcers and healing promotion. You
assess that the patient has understood the teaching by observing what?
A) Patient performs range-of-motion exercises.
B) Patient avoids placing her body weight on the healing site.
C) Patient elevates her body parts that are susceptible to edema.
D) Patient demonstrates the technique for massaging the wound site.
, ANS: B
The major goals of pressure ulcer treatment may include relief of pressure,
improved mobility, improved sensory perception, improved tissue perfusion,
improved nutritional status, minimized friction and shear forces, dry surfaces in
contact with skin, and healing of pressure ulcer, if present. The other options do
not demonstrate the achievement of the goal of the patient teaching.
3. An elderly female patient who is bedridden is admitted to the unit because of a
pressure ulcer that can no longer be treated in a community setting. During
your assessment of the patient, you find that the ulcer extends into the muscle
and bone. At what stage would document this ulcer?
A) I
B) II
C) III
D) IV
ANS: D
Stage III and IV pressure ulcers are characterized by extensive tissue damage. In
addition to the interventions listed for stage I, these advanced draining, necrotic
pressure ulcers must be cleaned (dÈbrided) to create an area that will heal. Stage
IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer
that extends into the subcutaneous tissue. With this type of ulcer, necrosis of
tissue and infection may develop. Stage I is an area of erythema that does not
blanch with pressure.
Stage II involves a break in the skin that may drain.
4. 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?
, A) Passive
B) Isometric
C) Resistive
D) Abduction
ANS: B
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.
5. An interdisciplinary team has been working collaboratively to improve the
health outcomes of a young adult who suffered a spinal cord injury in a
workplace accident. Which member of the rehabilitation team is the one who
determines the final outcome of the process?
A) Most-responsible nurse
B) Patient
C) Patient's family
D) Primary care physician
ANS: B
The patient is the key member of the rehabilitation team. He or she is the focus
of the team effort and the one who determines the final outcomes of the process.
The nurse, family, and doctor are part of the rehabilitation team but do not
determine the final outcome.
6. A school nurse is providing health promotion teaching to a group of high
school seniors. The nurse should highlight what salient risk factor for
traumatic brain injury?
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical
Nursing, 13th Edition
MULTIPLE CHOICE
1. The nurse is providing care for an older adult man whose diagnosis of
dementia has recently led to urinary incontinence. When planning this
patient's care, what intervention should the nurse avoid?
A) Scheduled toileting
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads
ANS: B
Indwelling catheters are avoided if at all possible because of the high incidence
of urinary tract infections with their use. Intermittent self-catheterization is an
appropriate alternative for managing reflex incontinence, urinary retention, and
overflow incontinence related to an overdistended bladder. External catheters
(condom catheters) and leg bags to collect spontaneous voiding are useful for
male patients with reflex or total incontinence. Incontinence pads should be
used as a last resort because they only manage, rather than solve, the
incontinence.
2. You are the nurse caring for a female patient who developed a pressure ulcer
as a result of decreased mobility. The nurse on the shift before you has
provided patient teaching about pressure ulcers and healing promotion. You
assess that the patient has understood the teaching by observing what?
A) Patient performs range-of-motion exercises.
B) Patient avoids placing her body weight on the healing site.
C) Patient elevates her body parts that are susceptible to edema.
D) Patient demonstrates the technique for massaging the wound site.
, ANS: B
The major goals of pressure ulcer treatment may include relief of pressure,
improved mobility, improved sensory perception, improved tissue perfusion,
improved nutritional status, minimized friction and shear forces, dry surfaces in
contact with skin, and healing of pressure ulcer, if present. The other options do
not demonstrate the achievement of the goal of the patient teaching.
3. An elderly female patient who is bedridden is admitted to the unit because of a
pressure ulcer that can no longer be treated in a community setting. During
your assessment of the patient, you find that the ulcer extends into the muscle
and bone. At what stage would document this ulcer?
A) I
B) II
C) III
D) IV
ANS: D
Stage III and IV pressure ulcers are characterized by extensive tissue damage. In
addition to the interventions listed for stage I, these advanced draining, necrotic
pressure ulcers must be cleaned (dÈbrided) to create an area that will heal. Stage
IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer
that extends into the subcutaneous tissue. With this type of ulcer, necrosis of
tissue and infection may develop. Stage I is an area of erythema that does not
blanch with pressure.
Stage II involves a break in the skin that may drain.
4. 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?
, A) Passive
B) Isometric
C) Resistive
D) Abduction
ANS: B
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.
5. An interdisciplinary team has been working collaboratively to improve the
health outcomes of a young adult who suffered a spinal cord injury in a
workplace accident. Which member of the rehabilitation team is the one who
determines the final outcome of the process?
A) Most-responsible nurse
B) Patient
C) Patient's family
D) Primary care physician
ANS: B
The patient is the key member of the rehabilitation team. He or she is the focus
of the team effort and the one who determines the final outcomes of the process.
The nurse, family, and doctor are part of the rehabilitation team but do not
determine the final outcome.
6. A school nurse is providing health promotion teaching to a group of high
school seniors. The nurse should highlight what salient risk factor for
traumatic brain injury?
