Title: ASN 210 W7 REHABILITATION NURSING
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I

Q: A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client’s activity tolerance?
- Vital signs before, during, and after activity
- Body image and self-care abilities
- Ability to use assistive or adaptive devices
- Client’s electrocardiography readings
A: Vital signs before, during, and after activity
If right: 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 client’s activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting.
If wrong: 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 client’s activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting.

Q: A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client’s teaching prior to beginning rehabilitation activities?
- “Use analgesics before and after activity, even if you are not experiencing pain.”
- “Let me know if you start to experience shortness of breath, chest pain, or fatigue.”
- “Do not take your prescribed beta blocker until after you exercise with physical therapy.”
- “If you experience knee pain, ask the physical therapist to reschedule your therapy.”
A: “Let me know if you start to experience shortness of breath, chest pain, or fatigue.”
If right: 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 client’s 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.
If wrong: 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 client’s 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.

Q: A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach?
- Use the bear-hug method to transfer the client safely.
- Ask several members of the health care team to carry the client.
- Utilize the facility’s mechanical lift to move the client.
- Consult physical therapy before performing all transfers.
A: Utilize the facility’s mechanical lift to move the client.
If right: 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.
If wrong: 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.

Q: A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
- Splint the joint and continue passive range of motion to the shoulder only.
- Progressively increase joint motion 5 degrees beyond resistance each day.
- Apply weights to the right distal extremity before initiating any joint exercise.
- Continue to move the joint only to the point at which resistance is met.
A: Continue to move the joint only to the point at which resistance is met.
If right: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance. Splinting the joint will not assist the client’s range of motion. The client’s joint should not be forced. Applying weights to the extremity will not increase range of motion of the joint but most likely will cause damage.
If wrong: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance. Splinting the joint will not assist the client’s range of motion. The client’s joint should not be forced. Applying weights to the extremity will not increase range of motion of the joint but most likely will cause damage.

Q: A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client’s risk of fracture?
- Apply shoes to improve foot support.
- Perform weight-bearing activities.
- Increase calcium-rich foods in the diet.
- Use pressure-relieving devices.
A: Perform weight-bearing activities.
If right: Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Although increasing calcium in the diet is a good intervention, this alone will not reduce the client’s susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.
If wrong: Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Although increasing calcium in the diet is a good intervention, this alone will not reduce the client’s susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.

Q: A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- Passive range of motion
- Active range of motion
- Resistive range of motion
- Aerobic exercise
A: Active range of motion
If right: Active range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living.
If wrong: Active range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living.

Q: A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
- Nutritional intake and serum albumin levels
- Pressure ulcer diameter and depth
- Wound drainage, including color, odor, and consistency
- Dressing site and antibiotic ointment application
A: Nutritional intake and serum albumin levels
If right: Assessing serum albumin levels helps determine the client’s nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.
If wrong: Assessing serum albumin levels helps determine the client’s nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.

Q: A nurse teaches a client about performing intermittent self-catheterization. The client states, “I am not sure if I will be able to afford these catheters.” How should the nurse respond?
- “I will try to find out whether you qualify for money to purchase these necessary supplies.”
- “Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.”
- “Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.”
- “You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.”
A: “You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.”
If right: At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client to the social worker to explore financial concerns. The nurse should not threaten the client, nor should the client be instructed to boil the catheters.
If wrong: At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client to the social worker to explore financial concerns. The nurse should not threaten the client, nor should the client be instructed to boil the catheters.

Q: A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP).  Which statement should the nurse include when delegating this task?
- “The client has skid-proof socks, so there is no need to use your gait belt.”
- “Teach the client how to use the walker while you are ambulating up the hall.”
- “Sit the client on the edge of the bed with legs dangling before ambulating.”
- “Ask the client if pain medication is needed before you walk the client in the hall.”
A: “Sit the client on the edge of the bed with legs dangling before ambulating.”
If right: Before the client gets out of bed, have the client sit on the bed with legs dangling on the side. This will enhance safety for the client. A gait belt should be used for all clients. The UAP cannot teach the client to use a walker or assess the client’s pain.
If wrong: Before the client gets out of bed, have the client sit on the bed with legs dangling on the side. This will enhance safety for the client. A gait belt should be used for all clients. The UAP cannot teach the client to use a walker or assess the client’s pain.

Q: A nurse assesses a client who is admitted with hip problems. The client asks, “Why are you asking about my bowels and bladder?” How should the nurse respond?
- “To plan your care based on your normal elimination routine.”
- “So we can help prevent side effects of your medications.”
- “We need to evaluate your ability to function independently.”
- “To schedule your activities around your elimination pattern.”
A: “To plan your care based on your normal elimination routine.”
If right: Bowel elimination varies from client to client and must be evaluated on the basis of the client’s normal routine. The nurse asks about bowel and bladder habits to develop a client-centered plan of care. The other answers are correct but are not the best responses. Oral analgesics may cause constipation, but they do not interfere with bladder control. The client is in rehabilitation to assist his or her ability to function independently. Elimination usually is scheduled around rehabilitation activities but should be taken into consideration when a plan of care is developed.
If wrong: Bowel elimination varies from client to client and must be evaluated on the basis of the client’s normal routine. The nurse asks about bowel and bladder habits to develop a client-centered plan of care. The other answers are correct but are not the best responses. Oral analgesics may cause constipation, but they do not interfere with bladder control. The client is in rehabilitation to assist his or her ability to function independently. Elimination usually is scheduled around rehabilitation activities but should be taken into consideration when a plan of care is developed.

Q: A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- Insert an indwelling urinary catheter.
- Stroke the medial aspect of the thigh.
- Use the Credé maneuver every 3 hours.
- Apply a Texas catheter with a leg bag.
A: Use the Credé maneuver every 3 hours.
If right: Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Credé maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag.
If wrong: Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Credé maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag.

Q: A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?
- Stroking the medial aspect of the thigh
- Valsalva maneuver
- Self-catheterization
- Frequent toileting
A: Valsalva maneuver
If right: With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voiding, such as with the Valsalva and Credé maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to re-establish voiding continence with an uninhibited bladder.
If wrong: With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voiding, such as with the Valsalva and Credé maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to re-establish voiding continence with an uninhibited bladder.

Q: A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- Place pillows under the client’s heels.
- Have the client do wheelchair push-ups.
- Perform wound care as prescribed.
- Massage the client’s calves and feet with lotion.
A: Have the client do wheelchair push-ups.
If right: Clients who sit for prolonged periods in a wheelchair should perform wheelchair push-ups for at least 10 seconds every hour. Chair-bound clients also need to be re-positioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed. Pillows under the heels could exert pressure on the heels; it is better to place the pillow under the ankle. Performing wound care as prescribed is important to improve the healing of pressure ulcers, but this intervention will not prevent skin breakdown. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.
If wrong: Clients who sit for prolonged periods in a wheelchair should perform wheelchair push-ups for at least 10 seconds every hour. Chair-bound clients also need to be re-positioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed. Pillows under the heels could exert pressure on the heels; it is better to place the pillow under the ankle. Performing wound care as prescribed is important to improve the healing of pressure ulcers, but this intervention will not prevent skin breakdown. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.

Q: A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?<br>1.   Apply a transfer belt around the client’s waist.<br>2.   Move the cane and left leg forward at the same time.<br>3.   Guide the client to a standing position.<br>4.   Move the right leg one step forward.<br>5.   Place the cane in the client’s right hand.<br>6.   Check balance and repeat the sequence.
- 3, 1, 5, 4, 2, 6
- 1, 3, 5, 2, 4, 6
- 5, 3, 1, 2, 4, 6
- 3, 5, 1, 4, 2, 6
A: 1, 3, 5, 2, 4, 6
If right: To ambulate a client with a cane, the nurse should first apply a transfer belt around the client’s waist, then guide the client to a standing position and place the cane in the client’s strong hand. Next the nurse should assist the client to move the cane and weaker leg forward together. Then move the stronger leg forward and check balance before repeating the sequence.
If wrong: To ambulate a client with a cane, the nurse should first apply a transfer belt around the client’s waist, then guide the client to a standing position and place the cane in the client’s strong hand. Next the nurse should assist the client to move the cane and weaker leg forward together. Then move the stronger leg forward and check balance before repeating the sequence.

Q: A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? <b>(Select all that apply.)</b>
- Achieving mobility
- Attaining independence with dressing
- Using a walker in public
- Learning techniques for transferring
- Performing activities of daily living (ADLs)
- Completing job training
A: Attaining independence with dressing; Performing activities of daily living (ADLs)
If right: The role of the occupational therapist is to assist the client with ADLs, dressing, and activities needed for job training. The physical therapist assists with muscle strength development and ambulation. Vocational counselors assist with job placement, training, and further education.
If wrong: The role of the occupational therapist is to assist the client with ADLs, dressing, and activities needed for job training. The physical therapist assists with muscle strength development and ambulation. Vocational counselors assist with job placement, training, and further education.

Q: An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? <b>(Select all that apply.)</b>
- Speech-language pathologist – Evaluates and retrains clients with swallowing problems
- Physical therapist – Assists clients with ambulation and walker training
- Recreational therapist – Assists physical therapists to complete rehabilitation therapy
- Vocational counselor – Works with clients who have experienced head injuries
- Registered dietitian – Develops client-specific diets to ensure client needs are met
A: Speech-language pathologist – Evaluates and retrains clients with swallowing problems; Physical therapist – Assists clients with ambulation and walker training; Registered dietitian – Develops client-specific diets to ensure client needs are met
If right: Speech-language pathologists evaluate and retrain clients with speech, language, or swallowing problems. Physical therapists help clients to achieve self-management by focusing on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet their needs for nutrition. Recreational therapists work to help clients continue or develop hobbies or interests. Vocational counselors assist with job placement, training, or further education.
If wrong: Speech-language pathologists evaluate and retrain clients with speech, language, or swallowing problems. Physical therapists help clients to achieve self-management by focusing on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet their needs for nutrition. Recreational therapists work to help clients continue or develop hobbies or interests. Vocational counselors assist with job placement, training, or further education.

Q: A rehabilitation nurse is caring for an older adult client who states, “I tire easily.” How should the nurse respond? <b>(Select all that apply.)</b>
- “Schedule all of your tasks for the morning when you have the most energy.”
- “Use a cart to push your belongings instead of carrying them.”
- “Your family should hire someone who can assist you with daily chores.”
- “Plan to gather all of the supplies needed for a chore prior to starting the activity.”
- “Try to break large activities into smaller parts to allow rest periods between activities.”
A: “Use a cart to push your belongings instead of carrying them.”; “Plan to gather all of the supplies needed for a chore prior to starting the activity.”; “Try to break large activities into smaller parts to allow rest periods between activities.”
If right: A cart is useful because it takes less energy to push items than to carry them. Gathering equipment before performing a chore decreases unneeded steps. Breaking larger chores into smaller ones allows rest periods between activities and still gives the client a sense of completion even if the client is unable to complete the whole task. Major tasks should be performed in the morning, when energy levels are high, while lesser tasks should be done throughout the day after frequent rest periods. Someone should be hired to do the chores only if the client cannot do them. The outcome should be achieving independence as close to the pre-disability level as possible.
If wrong: A cart is useful because it takes less energy to push items than to carry them. Gathering equipment before performing a chore decreases unneeded steps. Breaking larger chores into smaller ones allows rest periods between activities and still gives the client a sense of completion even if the client is unable to complete the whole task. Major tasks should be performed in the morning, when energy levels are high, while lesser tasks should be done throughout the day after frequent rest periods. Someone should be hired to do the chores only if the client cannot do them. The outcome should be achieving independence as close to the pre-disability level as possible.

Q: A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse’s role? <b>(Select all that apply.)</b>
- Maintain the safety of adaptive devices by monitoring their function and making repairs.
- Coordinate rehabilitation team activities to ensure implementation of the plan of care.
- Assist clients to identify support services and resources for the coordination of services.
- Counsel clients and family members on strategies to cope with disability.
- Support the client’s choices by acting as an advocate for the client and family.
A: Coordinate rehabilitation team activities to ensure implementation of the plan of care.; Support the client’s choices by acting as an advocate for the client and family.
If right: The rehabilitation nurse’s role includes coordination of rehabilitation activities to ensure the client’s plan of care is effectively implemented and advocating for the client and family. The biomedical technician monitors and repairs adaptive and electronic devices. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.
If wrong: The rehabilitation nurse’s role includes coordination of rehabilitation activities to ensure the client’s plan of care is effectively implemented and advocating for the client and family. The biomedical technician monitors and repairs adaptive and electronic devices. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.