Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman

Chapter 06: Rehabilitation Concepts for Chronic and Disabling Health Problems MULTIPLE CHOICE 1. A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the clients activity tolerance? a. Vital signs before, during, and after activity b. Body image and self-care abilities c. Ability to use assistive or adaptive devices d. Clients electrocardiography readings ANS: A To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the clients activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting. DIF: Applying/Application REF: 89 KEY: Rehabilitation care| functional ability MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statemen should the nurse include in this clients teaching prior to beginning rehabilitation activities? a. Use analgesics before and after activity, even if you are not experiencing pain. b. Let me know if you start to experience shortness of breath, chest pain, or fatigue. c. Do not take your prescribed beta blocker until after you exercise with physical therapy. d. If you experience knee pain, ask the physical therapist to reschedule your therapy. ANS: B Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the clients ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate cardiac rehabilitation plan. DIF: Applying/Application REF: 90 KEY: Rehabilitation care| nitroglycerin/nitrates| pain MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 3. A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach? a. Use the bear-hug method to transfer the client safely. b. Ask several members of the health care team to carry the client. c. Utilize the facilitys mechanical lift to move the client. d. Consult physical therapy before performing all transfers. ANS: C Use mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug method and the use of several members of the team to carry the client do not eliminate staff injuries. Physical therapy should be consulted but cannot be depended upon for all transfers. Nursing staff must be capable of transferring a client safely. DIF: Applying/Application REF: 93