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Medical Surgical Nursing 14th Edition TB Ch 10
kr kr kr kr kr kr kr
,
,Chapter 10: Principles and Practices of Rehabilitation
1. The nurse is providing care for an older adult man whose
diagnosis of dementia has recently led to urinarykr incontinence.
When planning this patients care, what intervention should the nurse
avoid?
A) Scheduled toileting
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads
Ans: B
Feedback:
Indwelling catheters are avoided if at all possible because of
the high incidence of urinary tract infections with their use.
kr
Intermittent self-catheterization is an appropriate alternative for
managing reflex incontinence, urinary retention,
kr and overflow incontinence
related to an overdistended bladder. External kr catheters (condom
catheters) and leg bags to collect spontaneous voiding are useful
for male patients with reflex or
kr total incontinence. Incontinence pads
should be used as a last resort because they only manage,
kr
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.
kr The
nurse on the shift before you has provided patient teaching
about pressure ulcers and healing
kr promotion. You assess that the
patient has understood the teaching by observing what? A)kr
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
Feedback:
The major goals of pressure ulcer treatment may include relief of
pressure, improved mobility, improved sensory
kr perception, improved
tissue perfusion, improved nutritional status, minimized friction and
shear forces,
kr dry surfaces in contact with skin, and healing of
pressure ulcer, if present. The other options do not demonstrate
kr 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
kr be
treated in a community setting. During your assessment of the
patient, you find that the ulcer extends into
kr the muscle and bone.
At what stage would document this ulcer?
A) I
B) II
C) III
D) IV
Ans: D
Feedback:
Stage III and IV pressure ulcers are characterized by extensive
tissue damage. In addition to the interventions
kr listed for
stage I, these advanced draining, necrotic pressure ulcers must be
cleaned (dbrided)
kr to create an area that will heal. Stage IV is
an ulcer that extends to underlying muscle and bone. kr Stage III is
an ulcer that extends into the subcutaneous tissue. With this type of
ulcer, necrosis of tissueand
kr infection may develop. Stage I is
an area of erythema that does not blanch with pressure. Stage II
kr
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
kr rehabilitation. You are
coaching the patient to contract and relax her muscles while keeping
Medical Surgical Nursing 14th Edition TB Ch 10
kr kr kr kr kr kr kr
,
,Chapter 10: Principles and Practices of Rehabilitation
1. The nurse is providing care for an older adult man whose
diagnosis of dementia has recently led to urinarykr incontinence.
When planning this patients care, what intervention should the nurse
avoid?
A) Scheduled toileting
B) Indwelling catheter
C) External condom catheter
D) Incontinence pads
Ans: B
Feedback:
Indwelling catheters are avoided if at all possible because of
the high incidence of urinary tract infections with their use.
kr
Intermittent self-catheterization is an appropriate alternative for
managing reflex incontinence, urinary retention,
kr and overflow incontinence
related to an overdistended bladder. External kr catheters (condom
catheters) and leg bags to collect spontaneous voiding are useful
for male patients with reflex or
kr total incontinence. Incontinence pads
should be used as a last resort because they only manage,
kr
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.
kr The
nurse on the shift before you has provided patient teaching
about pressure ulcers and healing
kr promotion. You assess that the
patient has understood the teaching by observing what? A)kr
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
Feedback:
The major goals of pressure ulcer treatment may include relief of
pressure, improved mobility, improved sensory
kr perception, improved
tissue perfusion, improved nutritional status, minimized friction and
shear forces,
kr dry surfaces in contact with skin, and healing of
pressure ulcer, if present. The other options do not demonstrate
kr 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
kr be
treated in a community setting. During your assessment of the
patient, you find that the ulcer extends into
kr the muscle and bone.
At what stage would document this ulcer?
A) I
B) II
C) III
D) IV
Ans: D
Feedback:
Stage III and IV pressure ulcers are characterized by extensive
tissue damage. In addition to the interventions
kr listed for
stage I, these advanced draining, necrotic pressure ulcers must be
cleaned (dbrided)
kr to create an area that will heal. Stage IV is
an ulcer that extends to underlying muscle and bone. kr Stage III is
an ulcer that extends into the subcutaneous tissue. With this type of
ulcer, necrosis of tissueand
kr infection may develop. Stage I is
an area of erythema that does not blanch with pressure. Stage II
kr
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
kr rehabilitation. You are
coaching the patient to contract and relax her muscles while keeping
