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A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?
- A. Cardiovascular system
- B. Respiratory system
- C. Endocrine system
- D. Neurovascular system
Correct Answer: D
Rationale: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
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A nurse is assisting a client with a neurologic deficit with bowel training. Which pharmacologic aid would the nurse anticipate to be used first?
- A. Stool softener
- B. Bulk forming
- C. Stimulant
- D. Lubricant
Correct Answer: A
Rationale: When using a pharmacologic aid, the nurse would anticipate using the mildest form first beginning with a stool softener. Stool softeners moisturize the feces, which facilitates passage of stool without straining. The other Classifications could also be appropriate but not used first.
A nurse is caring for a client with a neurologic deficit whose condition has stabilized. What phase of the neurologic deficit begins now?
- A. Recovery
- B. Chronic
- C. Terminal
- D. Acute
Correct Answer: A
Rationale: The recovery phase begins when the client's condition is stabilized. It starts several days or weeks after the initial event and lasts weeks or months. This makes the other options incorrect.
The nurse is caring for a client in the chronic phase of a neurologic deficit. The nurse knows that nursing management in this phase focuses on what?
- A. Working with team members to plan a rehabilitation program
- B. Retraining the client's bowel and bladder
- C. Supporting the client during recovery
- D. Preventing physical and psychological complications
Correct Answer: D
Rationale: Nursing management of clients in the chronic phase of a neurologic deficit focuses on preventing physical and psychological complications. Planning a rehabilitation program occurs during the recovery phase, as would retraining the client's bowel and bladder, if possible, and supporting the client's recovery.
A nurse is caring for a client with slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.
- A. Offer a communication board.
- B. Encourage exercises such as whistling.
- C. Allow time for the client to respond to questions.
- D. Guess words the client has difficulty saying and confirm understanding with the client.
- E. Provide sensory aids.
Correct Answer: A,C,D
Rationale: The nurse should offer a communication board to the client, allow time for the client to respond to questions, and guess words the client has difficulty saying and confirm understanding with the client. Encouraging exercises such as whistling are appropriate for a client with dysarthria, not expressive aphasia. Providing sensory aids such as glasses is a technique appropriate for a client with receptive aphasia, not expressive aphasia.
The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema?
- A. Tape the client's buttocks together so to retain the enema.
- B. Instill the mini enema slowly (1 to 2 oz at a time) followed by a waiting period.
- C. Prop the client over a toilet to allow gravity to assist in the defecation process.
- D. Insert the enema tubing high into the bowel to increase fecal mass elimination.
Correct Answer: B
Rationale: The best nursing action is to instill the enema solution slowly and allow a waiting period. By doing so, the enema solution has the best opportunity to be effective. The nurse would tape the buttocks together when administering a suppository. Propping the client over the toilet would allow the enema solution to be expelled immediately. Enema tubing is inserted carefully into the rectum and not advanced high into the colon.