You are the nurse making the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who had a stroke but who had lived independently until this event
What goal would you know is appropriate for this patient?
A) Maintenance of joint mobility
B) Refer to social services
C) Ambulate three times every day
D) Perform passive range of motion twice daily
Ans: A
Feedback: The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. Options B, C, and D are incorrect because they are not goals; they are nursing interventions.
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A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status?
A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.
A patient says, "My physician thinks I may have psoriatic arthritis, but there is nothing wrong with my skin.". How should the nurse respond?
1. "You must have a subclinical case of psoriasis.". 2. "You will probably develop skin eruptions in a few years.". 3. "Not all people with psoriatic arthritis also have psoriasis.". 4. "There are other arthritis conditions that have similar laboratory values, so additional testing will be likely.".
The nurse inserts an indwelling urinary catheter into the client's bladder and urine begins to drain; however, when the balloon is inflated, the client reports sharp stabbing pain. What should the nurse implement next?
1. Deflate the balloon. 2. Remove the catheter. 3. Advance catheter 2 inches. 4. Reassure client it will pass.
The postpartum client is about to go home. The nurse includes which subject in the teaching plan?
1. Replacement of fluids 2. Striae 3. Diastasis of the recti muscles 4. REEDA scale