Chapter 07: Concepts of Rehabilitation for
Chronic and Disabling Health Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse plans care for a client who is bedridden. Which assessment would the nurse
complete to ensure to prevent pressure injury formation?
a. Nutritional intake and serum albumin levels
b. Pressure injury diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application
ANS: A
Assessing serum albumin levels helps determine the client’s nutritional status and
allows care providers to alter the diet, as needed, to provide protein to prevent
pressure injuries. All other options are treatment oriented rather than prevention
oriented.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Rehabilitation care, Tissue integrity MSC:
Client Needs Category: Physiological Integrity: Physiological Adaptation
2. 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 would the nurse
respond?
a. “I will try to find out whether you qualify for money to purchase these
necessary supplies.”
, b. “Even though it is expensive, the cost of taking care of urinary tract infections
would be even higher.”
c. “Instead of purchasing new catheters, you can boil the catheters and reuse
them up to 10 times each.”
d. “I will contact the social worker who will discuss potential resources with
you.”
ANS: D
Social workers help patients identify support services and resources, including
financial assistance. The nurse would refer the client to the social worker to explore
financial concerns. The nurse would not threaten the client, nor would the client be
instructed to boil the catheters.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Rehabilitation care, Interprofessional team MSC: Client
Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse delegates the ambulation of an older adult client to a nursing assistant. Which
statement would the nurse include when delegating this task?
a. “The client has skid-proof socks, so there is no need to use your gait belt.”
b. “Teach the client how to use the walker while you are ambulating up the hall.”
c. “Sit the client on the edge of the bed with legs dangling before ambulating.”
d. “Ask the client if pain medication is needed before you walk the client.”
ANS: C
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 because it gives the body time to
adjust after changing position and can prevent safety concerns from orthostatic
hypotension. A gait belt would be used for all clients. The nursing assistant cannot
teach the client to use a walker or assess the client’s pain.
Chronic and Disabling Health Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse plans care for a client who is bedridden. Which assessment would the nurse
complete to ensure to prevent pressure injury formation?
a. Nutritional intake and serum albumin levels
b. Pressure injury diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application
ANS: A
Assessing serum albumin levels helps determine the client’s nutritional status and
allows care providers to alter the diet, as needed, to provide protein to prevent
pressure injuries. All other options are treatment oriented rather than prevention
oriented.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Rehabilitation care, Tissue integrity MSC:
Client Needs Category: Physiological Integrity: Physiological Adaptation
2. 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 would the nurse
respond?
a. “I will try to find out whether you qualify for money to purchase these
necessary supplies.”
, b. “Even though it is expensive, the cost of taking care of urinary tract infections
would be even higher.”
c. “Instead of purchasing new catheters, you can boil the catheters and reuse
them up to 10 times each.”
d. “I will contact the social worker who will discuss potential resources with
you.”
ANS: D
Social workers help patients identify support services and resources, including
financial assistance. The nurse would refer the client to the social worker to explore
financial concerns. The nurse would not threaten the client, nor would the client be
instructed to boil the catheters.
DIF: Applying TOP: Integrated Process: Teaching/Learning
KEY: Rehabilitation care, Interprofessional team MSC: Client
Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse delegates the ambulation of an older adult client to a nursing assistant. Which
statement would the nurse include when delegating this task?
a. “The client has skid-proof socks, so there is no need to use your gait belt.”
b. “Teach the client how to use the walker while you are ambulating up the hall.”
c. “Sit the client on the edge of the bed with legs dangling before ambulating.”
d. “Ask the client if pain medication is needed before you walk the client.”
ANS: C
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 because it gives the body time to
adjust after changing position and can prevent safety concerns from orthostatic
hypotension. A gait belt would be used for all clients. The nursing assistant cannot
teach the client to use a walker or assess the client’s pain.
