Nokea
A nurse is caring for a client diagnosed with neurologic deficit who has recently become responsive when interacted with. What therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
- A. Occupational therapy
- B. Range-of-motion (ROM) exercises
- C. Recreational therapy
- D. Music Therapy
Correct Answer: A
Rationale: Occupational therapy is designed to help strengthen muscles that are under voluntary control. ROM exercises maintain joint flexibility and prevent permanent contractures. Participation in recreational and music therapies increases socialization time.
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The nurse is instructing the client on how to perform Cred?© maneuver. In which situation is this maneuver helpful?
- A. When a client is experiencing a vagal response during a bowel movement
- B. When a client is experiencing orthostatic hypotension upon arising
- C. When a client is attempting to empty the bladder
- D. When a client is experiencing numbness of the lower extremities
Correct Answer: C
Rationale: Cred?©'s maneuver is intended to increase abdominal pressure and facilitate the emptying of the bladder. The nurse instructs the client to bend at the waist or press inward and downward over the bladder. The other options are not correct.
In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?
- A. Transient ischemic attack (TIA)
- B. Malignant brain tumor
- C. Alzheimer disease
- D. Pneumonia
Correct Answer: C
Rationale: Clients with Alzheimer disease are often admitted to the hospital for treatment of complications. Sometimes, when their disease process progresses, they are also admitted to a skilled nursing facility. A transient ischemic attack causes transient symptoms or minor neurologic deficits. A malignant brain tumor typically causes debilitating symptoms and spreads due to the malignant nature causing death. Pneumonia is a complication of neurologic deficits, but itself is not a neurologic deficit. Pneumonia can be resolved with antibiotics depending on the status of the client.
The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct?
- A. Lightly massage or tap the skin above the pubic area.
- B. Press directly over the urinary bladder.
- C. Bear down increasing abdominal pressure.
- D. Pour water over the genitals.
Correct Answer: A
Rationale: Cutaneous triggering performed by massaging or tapping lightly over the pubic area stimulates relaxation of the urinary sphincter. Pressing over the urinary bladder is a component of the Cred?© maneuver, which does not relax the urinary sphincter. Bearing down with mouth and nose shut is a component to the Valsalva maneuver. Pouring water over the genitals is ineffective in a paralyzed client.
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.
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
- A. Provide instruction on blood-thinning medication.
- B. Praise client when using adaptive equipment.
- C. Include client in planning of care and setting of goals.
- D. Assess client for ability to ambulate independently.
Correct Answer: C
Rationale: The client in a rehabilitation setting has moved to the recovery phase. The highest priority is to include the client in the rehabilitation plan. Tailoring the rehabilitation plan to meet the needs of the client can promote optimal participation by the client in the rehabilitative process. The other options are appropriate in certain situations but not the highest priority.