Medical Surgical Nursing 6th Edition Ignatavicius Test Bank Download

Medical Surgical Nursing 6th Edition
Ignatavicius Test Bank

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Ignatavicius: Medical-Surgical Nursing, 6th Edition
Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health Problems
Test Bank
MULTIPLE CHOICE
1. Primary prevention interventions for older adults should include prevention of which condition?
a. Accidents
b. Morbid obesity
c. Coronary artery disease
d. Diabetes mellitus type 2
ANS: A
Although stroke is the leading cause of disability in the United States, many younger adults are
disabled from accidents rather than from disease. Morbid obesity, coronary artery disease, and
diabetes mellitus type 2 are diseases/common chronic conditions that may result in varying
degrees of disability. Most occur in people older than 65 years.
DIF: Cognitive Level: Comprehension REF: pp. 94-95

OBJ: Learning Outcomes 1, 4
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
Control) MSC: Integrated Process: Nursing Process (Assessment)
2. How is a handicap different from an impairment, as defined by the World Health Organization?
a. An impairment may be temporary and a handicap is usually permanent.
b. Handicaps only involve mobility and an impairment may involve any organ
structure or function.
c. Impairments are physical abnormalities and handicaps are societal values placed
on individuals with impairments.
d. Handicaps are societal attempts to improve the functional ability of a person with
an impairment, allowing more mainstream integration.
ANS: C
A handicap is a preventable and reversible disturbance at the societal level that is experienced by
a person with a disability or impairment. It is a negative value that is ascribed to the person, the
disability, or the impairment. A handicap is often described by what a person is perceived to be
unable to perform.
DIF: Cognitive Level: Knowledge REF: p. 95

OBJ: Learning Outcome 11
TOP: Client Needs Category: Psychosocial Integrity (Behavioral Interventions)
MSC: Integrated Process: Nursing Process (Assessment)
3. The nurse is planning discharge teaching about rehabilitation for the client who is paraplegic.
The client verbalizes that he doesn’t know why he should go. What is the nurse’s best response?
Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Test Bank 8-2
a. “Your doctor ordered rehabilitation, and he does know what is best for you.”
b. “When new discoveries are made, people in rehabilitation programs will benefit
first.”
c. “Rehabilitation will teach you how to maintain the functional ability you have.”
d. “You are right. I will cancel the orders for rehabilitation.”
ANS: C
There are many purposes for participating in rehabilitation programs, including disability
prevention, maintenance of functional ability, and restoration of function. Without the special
knowledge learned through rehabilitation, the client with a newly acquired disability may never
learn the skills needed to prevent long-term problems or conserve energy.
DIF: Cognitive Level: Application REF: N/A for Application and above
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion
Programs) MSC: Integrated Process: Nursing Process (Implementation)
4. The client who has long-standing chronic obstructive pulmonary disease (COPD) is recovering
from a stroke. Which intervention is a priority when caring for the client to assess activity
tolerance during rehabilitation?
a. Assessing vital signs before, during, and after activity
b. Performing cognitive assessment
c. Measuring arterial blood gases frequently
d. Keeping client on bedrest
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 cognitive assessment is not necessary prior to
basic activities. Arterial blood gases are not measured frequently because of the invasive nature
of the test. A client should not be kept on bedrest unless she or he is unable to tolerate standing,
sitting, or ambulating.
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation)
MSC: Integrated Process: Nursing Process (Evaluation)
5. A client with a past history of angina has had a total knee replacement. What will the nurse teach
the client prior to rehabilitation activities?
a. “Use analgesics even if you are not in pain.”
b. “Take nitroglycerine prophylactically prior to activity.”
c. “Take anti-inflammatory medications before you get out of bed.”
d. “Do not exercise if you have knee pain.”
ANS: B
Test Bank 8-3
Participation in exercise may increase myocardial oxygen demand beyond the ability of the
coronary circulation to deliver enough oxygen to meet the increased need. Nitroglycerin dilates
coronary arteries within 5 minutes of use, ensuring that they will be ready to meet the demand
during exercise.
TOP: Client Needs Category: Psychosocial Integrity (Coping Mechanisms)
MSC: Integrated Process: Teaching/Learning
6. The nurse is assessing a client who has recently had a brain attack for the ability to toilet
independently. What should the nurse assess in establishing level of independence for toileting?
a. The medications that the client is taking
b. The frequency of the stool
c. The amount of urine that the client voids
d. The ability to sit on the toilet unassisted
ANS: D
A client should be able to sit on the toilet unassisted to be independent with toileting. The other
aspects may affect the frequency of toileting and may tire the client, requiring assistance for
safety purposes, or may require a bedside commode.
DIF: Cognitive Level: Comprehension REF: p. 108

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care)
MSC: Integrated Process: Nursing Process (Planning)
7. What test will best assist the nurse in determining the severity of a client’s disability?
a. Instrumental activities of daily living (IADLs)
b. Minimum data set (MDS)
c. Functional independence measure (FIM)
d. Independent living skills test (ILST)
ANS: C
The functional independence measure is a uniform data set used for outcome data collection in
the United States. The FIM attempts to quantify what the person actually does, whatever the
diagnosis or impairment. Categories for assessment are self-care, sphincter control, mobility,
locomotion, communication, and cognition. IADLs is a functional assessment tool carried out by
numerous members of the interdisciplinary team in the health care setting. The MDS is used to
assess nursing home residents in areas of motor ability, sensations, and cognitions as well as
overall health status.
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
Test Bank 8-4
8. What is the priority nursing diagnosis for a client in a rehabilitation program after a stroke that
has caused extensive right-sided weakness?
a. Self-Care Deficit: hygiene, feeding, toileting
b. Risk for Impaired Skin Integrity
c. Constipation
d. Impaired Physical Mobility
ANS: B
The client has a self-care deficit and impaired physical mobility. These problems greatly increase
the risk for the client to experience skin breakdown, complicating or interfering with the
recovery and rehabilitation efforts. Impaired mobility can lead to constipation, which is
uncomfortable and can lead to intestinal problems. Risk for impaired skin integrity is the highest
priority. First, it can lead to infection, local or systemic. It causes discomfort, prolongs
hospitalization, and delays rehabilitation. It also will result in decreased financial and insurance
reimbursement.
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Environment)
9. The nurse is assessing the client’s ability to transfer from the bed to the wheelchair. What might
impair the client’s ability to perform this task?
a. Recent weight gain
b. Expressive aphasia
c. Bowel and bladder incontinence
d. Strong upper arm strength
ANS: A
With impaired mobility and use of a wheelchair, the client tends to gain weight. The increased
weight requires greater upper body strength for movement and hinders the client’s ability to
become independent in transfer. Expressive aphasia deals with communication on the client’s
part. This has little to do with transfer. Incontinence puts the client at risk for skin breakdown.
Strong upper arm strength would decrease a chance of problems with transfer.

10. The nurse is performing passive range-of-joint motion exercises on a semiconscious client and
meets resistance while attempting to extend the right elbow more than 45 degrees. What will the
nurse do?
a. Splint the joint and continue the passive range of motion to the shoulder only.
b. Progressively increase the joint motion 5 degrees beyond the resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Move the joint only to the point at which resistance is met.
Test Bank 8-5
ANS: D
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 the range of motion of the joint, but will most likely cause damage.
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
11. What intervention will best help a client with decreased mobility decrease the risk of fractures?
a. Applying a foot support
b. Performing weight-bearing activities
c. Increasing calcium-rich foods in the diet
d. Using pressure-relieving devices
ANS: B
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 fractures. Although
increasing the calcium in the diet is a good intervention, this alone will not reduce the client’s
susceptibility to bone fractures. A foot support and pressure relieving devices will not help
prevent fractures, but may help with mobility and skin integrity.
MSC: Integrated Process: Nursing Process (Implementation)
12. The nurse assesses a client admitted for rehabilitation. The client has full range of motion, but
presents with a weak grasp. What exercise does the nurse perform?
a. Passive range of motion (ROM)
b. Active range of motion
c. Resistive range of motion
d. Aerobic exercise
ANS: C
Resistive ROM involves gradually and progressively adding gentle resistance to a range-of-
motion exercise, promoting an increase in strength of the muscles required to move the joint. The
client needs to strengthen the muscle groups related to grasp. Because the client already has full
range of motion, active and passive ROM exercises are not needed. Aerobic exercises are not
used for weak grasp.
Test Bank 8-6
13. Which assessment finding would prevent a client from being a candidate for self-catheterization?
a. Arthritis
b. Blindness
c. Confusion
d. Paraplegia
ANS: C
Clients of any age with a variety of impairments and disabilities can participate in intermittent
self-catheterization. The two main requirements are that the client be cognitively intact and can
reach the area.
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort)
14. Which action will the nurse implement to prevent pressure ulcer formation in a bedridden client?
a. Adjusting nutritional intake based on serum albumin and transferrin levels
b. Measuring the ulcer diameter and depth every shift
c. Changing the gauze dressing whenever drainage is observed
d. Applying antibiotic ointment to all excoriated skin areas
ANS: A
Assessing serum and transferrin levels helps determine the client’s nutritional status and allows
the care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are
treatment-oriented rather than prevention-oriented.
TOP: Client Needs Category: Health Promotion and Maintenance (Disease Prevention)
15. The client has left-sided weakness. Which gait-training technique will the physical therapist and
nurse use when assisting the client to walk with a cane?
a. Placing the cane in the client's weaker hand and moving the cane forward,
followed by moving the weaker leg one step forward
b. Placing the cane in the client’s weaker hand and moving the cane forward,
followed by moving the stronger leg one step forward
c. Placing the cane in the client’s stronger hand and moving the cane forward,
followed by moving the weaker leg one step forward
d. Placing the cane in the client’s stronger hand and moving the cane forward,
followed by moving the stronger leg one step forward
ANS: C
Placing the cane in the client’s weaker hand does not provide sufficient stability. After the cane
in the stronger hand is moved ahead, the cane and the stronger leg provide a stable base for
movement of the weaker leg.
Test Bank 8-7
16. Which nursing intervention will the nurse implement to prevent venous stasis and thrombus
formation in a client undergoing rehabilitation?
a. Range-of-motion exercises
b. Foot support while in bed
c. Increased dietary calcium intake
d. Avoidance of sudden position changes
ANS: A
Range-of-motion exercises involve skeletal muscle contraction of the upper and lower
extremities. Muscle contraction promotes venous return, preventing stasis and thrombus
formation.
17. Which activity plan would best conserve a client’s energy without compromising the client’s
physical or mental health?
a. Reducing hygiene activities and restricting visitors
b. Ensuring that the client toilets before and after any other planned activity
c. Scheduling energy-intensive activities in the morning when energy levels are high
d. Scheduling as many activities as possible in a small block of time
ANS: C
Some of the best techniques for energy conservation include spacing activities with a rest period
in between and individualizing the scheduling of more energy-intensive activities to the time of
day when the client knows or feels that his or her energy levels are higher.
18. Which dietary modification will the nurse reinforce to reduce the risk for skin impairment in a
client with impaired physical mobility?
a. High-protein, high-carbohydrate, low-fat diet
b. High-protein, low-carbohydrate, low-fat diet
c. High-protein, high-carbohydrate, high-fat diet
d. High-protein, low-carbohydrate, high-fat diet
ANS: A
Test Bank 8-8
The goal of nutrition therapy is to provide sufficient nutrients to promote wound healing, prevent
skin breakdown, and avoid gaining excessive weight. The two most important nutrients to
stimulate cell division and prevent loss of muscle mass are carbohydrates and proteins.
19. A nurse catheterizes a client immediately after voiding. The residual volume is 50 mL. What will
the nurse do next?
a. Notify the physician.
b. Insert an indwelling catheter.
c. Document the finding as the only action.
d. Modify or extend the bladder-training program.
ANS: C
This finding is normal. Therefore, the nurse should document the finding and continue with the
present bladder-training program. The goals of a bladder-training program are to avoid the use of
an indwelling catheter and keep the residual volume at less than 100 mL.
TOP: Client Needs Category: Health Promotion and Maintenance (Health and Wellness)
20. The client who is performing intermittent self-catheterization at home is concerned about the
cost of the catheters. What is the nurse’s best response?
a. “I will try to find out whether or not 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. “You can boil the catheters and reuse them up to 10 times each.”
d. “You can reuse the catheters at home. Clean technique, rather than sterile
technique, is acceptable.”
ANS: D
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.

MSC: Integrated Process: Teaching/Learning
Test Bank 8-9
21. The nurse teaches the client at risk for urinary tract infections to increase which beverage in their
diet?
a. Carbonated beverages
b. Citric juices
c. Milk
d. Tomato juice
ANS: D
Some organisms, such as Escherichia coli, do not grow well in an acidic environment. Fluids
that promote an acidic urine include cranberry juice, prune juice, bouillon, tomato juice, and
water.
22. An older adult client is getting out of bed for the first time. The nurse is alert for the development
of which potential problem?
a. Deep vein thrombosis (DVT)
b. Incontinence
c. Orthostatic hypotension
d. Pulmonary embolism
ANS: C
The older client with cardiac disease or on antihypertensive medications is particularly at risk for
orthostatic hypotension. The client would be a risk for DVT or pulmonary embolism the longer
he or she remained on bed rest. Incontinence has nothing to do with getting out of bed.
23. A paraplegic client is being evaluated for transfer to a rehabilitation unit. The nurse refers the
client to which interdisciplinary team member for evaluation of activities of daily living?
a. Physical therapist
b. Occupational therapist
c. Recreational therapist
d. Vocational therapist
ANS: B
The occupational therapist is responsible for ADL training, the physical therapist for muscle
strength, the vocational therapist for job training, and the recreational therapist for hobbies or
pastime activities.
Test Bank 8-10
24. The nurse performs an admission history on a client who has been transferred to a rehabilitation
floor of the hospital. The client asks, “Why are you doing this again? They took my history on
the other floor.” How will the nurse respond?
a. “I need to formulate an individualized plan of care.”
b. “This will assist in building your self-esteem.”
c. “I need to establish a baseline assessment.”
d. “We have to determine who can best care for you.”
ANS: A
Although all the responses can be correct to some extent, the need to formulate an individualized
plan of care is most correct. The other activities will add to or be an outcome of the plan of care.
The assessment establishes the client’s normal routine, abilities, and activity tolerance to
establish interventions developed specifically for this client.
25. Prior to ambulating a client, what information is essential for the nurse to know?
a. When the client last ate
b. That the client is depressed
c. That the pulse oximetry is 95%
d. That the client has on a nitroglycerin patch
ANS: D
Although all can affect the client’s ability to ambulate, a nitroglycerin patch can cause a drop in
blood pressure on standing (orthostatic hypotension) and therefore can be a safety factor.
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection
Control) MSC: Integrated Process: Nursing Process (Planning)
26. During the admission history intake, a client with hip problems asks, “Why are you asking about
my bowels and bladder?” What is the nurse’s best response?
a. “To plan your care based on your normal elimination routine.”
b. “To help prevent side effects of your medications.”
c. “We need to evaluate your ability to function independently.”
d. “It is best to schedule your activities around your elimination pattern.”
ANS: A
Test Bank 8-11
Bowel elimination varies from client to client and needs to be evaluated based on the client’s
normal routine. Oral analgesics may cause constipation, but don’t interfere with bladder control.
Elimination is usually scheduled around the activities. The client is in rehabilitation to assist her
or his ability to function independently.
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
27. A client is starting on a structured cardiac rehabilitation program. Before starting the activity,
what will the nurse do?
a. Administer nitroglycerin to increase the blood flow to the heart.
b. Refer the client for psychological testing related to fear of death.
c. Start oxygen at 2 L/min via nasal cannula.
d. Determine the level of activity before shortness of breath occurs.
ANS: D
The level of activity that can be accomplished without experiencing shortness of breath needs to
be established prior to activity. This will alleviate fear and anxiety and prevent the occurrence of
cardiac symptoms. Oxygen should only be started if the pulse oximetry reading is below 90% or
if there are electrocardiographic changes or cardiac symptoms, none of which are indicated in
this question. The client does not require psychological testing at this time because the fear that
he or she feels is related to something real. If the fear continues, a referral can be made.

28. The nurse is caring for a client with a spinal cord injury at level T3. How will the nurse assist the
client with bladder dysfunction?
a. Inserts an indwelling urinary catheter
b. Monitors the amount of fluid intake
c. Uses Credé’s maneuver for the bladder every 3 hours
d. Applies a Texas catheter with leg bag
ANS: C
If the spinal cord injury is above T12, the client is unaware of a full bladder and therefore does
not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a
leg bag. The client needs to be straight-catheterized when the bladder is full, which is determined
by palpating the bladder (Credé’s maneuver). Indwelling urinary catheters are not generally used
because of the increased incidence of urinary tract infections. Fluid intake need to be monitored,
ensuring that adequate amount of fluids are taken in. Fluids should not be restricted unless for
another medical problem.
Test Bank 8-12

29. A client with a flaccid bladder is undergoing bladder training. The nurse begins the client’s
bladder training by teaching which technique?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver and Credé’s maneuver
c. Self-catheterization
d. Frequent toileting
ANS: B
With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be
needed to initiate voiding, the Valsalva and Credé maneuvers. Intermittent catheterization may
be used after attempting the previous maneuvers. 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.
Consistent toileting routine is used to re-establish voiding continence with an uninhibited
bladder.
30. The client is receiving the following medications: levothyroxine (Synthroid) at 7 AM and
digoxin (Lanoxin) at 9 AM. What would be the best time to administer the psyllium
(Metamucil)?
a. 0700
b. 0900
c. 1100
d. 1300
ANS: D
Synthroid needs to be given before meals. There should be at least 4 hours between the
administration of Metamucil and digoxin because of the interference in absorption of the digoxin
by the Metamucil.
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral
Therapies) MSC: Integrated Process: Nursing Process (Planning)
MULTIPLE RESPONSE
1. The physical therapist’s role is to help the client with which of the following activities? (Select
all that apply.)
a. Achieving mobility
Test Bank 8-13
b. Attaining independence dressing

c. Using a walker in public
d. Learning techniques for transferring
e. Performing activities of daily living
f. Job training
ANS: A, C, D
The role of the physical therapist is to assist in muscle strength development and ambulation.
The occupational therapist deals with the ADLs, dressing, and activities needed for job training.
DIF: Cognitive Level: Knowledge REF: p. 96

2. An older adult client tells the nurse that “I tire easily.” Which activities best assist the client to
conserve energy? (Select all that apply.)
a. Performs all tasks in the morning, and rests for the remainder of the day
b. Takes frequent rest periods
c. Gathers all supplies needed for a chore
d. Uses a cart, bag, or tray to carry items
e. Pushes objects rather than lifting them
f. Breaks large activities into smaller parts, resting in between
g. Hires someone to assist with chores
ANS: B, C, D, E, F
Major tasks should be performed in the morning, when energy levels are high. Lesser tasks
should be done throughout the day after frequent rest periods. Gathering equipment prior to a
chore decreases unneeded steps. Carrying more than one or two items at a time will save time
and energy. It takes less energy to push items than to carry them. Breaking larger chores into
smaller ones allows rest periods between activities and gives the client a sense of completion if
unable to complete the whole task. Hiring someone to do the chores should only be done if the
client cannot do them. The outcome should be achieving independence as close as possible to the
predisability level.
3. Which of the following will the nurse do for clients who are wheelchair bound to prevent skin
breakdown? (Select all that apply.)
a. Change their position every 1 to 2 hours.
b. Place pillows under their heels.
c. Have them do wheelchair pushups.
d. Remove their shoes to check for pressure areas.
e. Assess their lower legs for pressure from the wheelchair.
Test Bank 8-14
f. Massage their calves and feet with lotion.

ANS: A, C, D, E
Clients who sit for prolonged periods in a wheelchair need to be repositioned at least every 1 to 2
hours. Wheelchair pushups should be done for at least 10 seconds every hour. If the client is
wearing tennis shoes to prevent footdrop, the shoes should be removed every 2 hours to check
for pressure areas. The lower legs, where the legs of the wheelchair could rub against their legs,
also needs to be assessed. Pillows under the heels could exert pressure on the heels. It is better to
place the pillow under the ankle. Massaging the calves of a client with no or decreased lower
extremity mobility should not be done because of the risk of embolization or thrombus.
4. Which abnormal findings in a client with a disabling condition would alert the nurse to an
increased risk for skin breakdown? (Select all that apply.)
a. Low serum albumin level
b. High serum transferrin level
c. Low serum carboxyhemoglobin
d. High serum hematocrit
e. Increased weight gain
f. Incontinence
g. Poor fluid intake
ANS: A, E, F, G
A low serum albumin level indicates less than adequate nutrition, especially of proteins, which
greatly increases the risk for skin breakdown and reduces the rate of wound healing. Protein is a
critical nutrient for stimulating DNA synthesis, cell division, and tissue repair. Increased weight
gain makes it more difficult to move and puts more pressure on pressure areas. Incontinence,
bowel or bladder, irritates the skin, making it more prone to breakdown.

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Medical Surgical Nursing 6th Edition

Ignatavicius Test Bank

Chapter 8: Rehabilitation Concepts for Chronic and Disabling Health Problems

DIF: Cognitive Level: Comprehension REF: pp. 94-95

DIF: Cognitive Level: Knowledge REF: p. 95

DIF: Cognitive Level: Comprehension REF: p. 108

DIF: Cognitive Level: Comprehension REF: p. 100

DIF: Cognitive Level: Comprehension REF: p. 106

DIF: Cognitive Level: Comprehension REF: p. 97

OBJ: Learning Outcomes 6, 7

b. Attaining independence dressing

DIF: Cognitive Level: Knowledge REF: p. 96

f. Massage their calves and feet with lotion.

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