Chapter 39 rehabilitation Flashcards
(31 cards)
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.
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
ANS: D
The underlying philosophy of rehabilitation is to focus on the abilities of the patient.
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 patient’s adaptation to a new lifestyle.
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.
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
ANS: C
The occupational therapist recommends adaptive equipment or helps in modifying skills to
enhance independence.
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.
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.
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 rehabili tation 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-t raining and flexibility to reduce a duplication of efforts.
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.
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.
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.
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
ANS: A
Gerontological rehabilitation nursing focuses on the unique requirements of older adult
rehabilitation. The elderly, with their potential physical limitations, require specialized care.
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.
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 patient’s 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.
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.
- 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.
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 autonomicdysreflexia?
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 injuries, 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.
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.
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 supportsystem
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.
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
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 one’s normal functioning. A chronic illness is an
irreversible lifelong impairment.
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.
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.
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.
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.
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.
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.
