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A nurse is caring for a client who has a neurologic deficit. What would the nurse do to assist this client in increasing peristalsis and encouraging defecation?
- A. Help the client to the bathroom at a particular time each day.
- B. Administer a low-volume enema each day at the same time.
- C. Encourage liquids throughout the day.
- D. Encourage a high-fiber diet.
Correct Answer: A
Rationale: Helping the client to the bathroom at a particular time each day increases peristalsis and encourages defecation because of the physical activity involved in getting out of bed. Administering a low-volume enema stimulates a bowel movement. Increase in fluid intake and a high-fiber diet will aid in normalizing bowel movements.
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A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
- A. Use the Glasgow Coma Scale.
- B. Use the Mini-Mental Status Examination.
- C. Report the change to the physician.
- D. Monitor the blood pressure.
Correct Answer: C
Rationale: When significant changes occur, the nurse should immediately report them to the physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools, such as the Mini-Mental Status Examination, to perform the neurologic assessments to evaluate the client's status. The nurse maintains the blood pressure to ensure adequate cerebral oxygenation.
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.
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. Which occupation(s) is anticipated to improve the functioning of this client? Select all that apply.
- A. Occupational therapist
- B. Speech therapist
- C. Electrocardiography technician
- D. Electroencephalogram technician
- E. Physical therapist
Correct Answer: A,B,E
Rationale: The following occupations work with the client with neurologic deficits and improve functioning: The occupational therapist improves fine motor movement and assists with instructing on assistive devices. A speech therapist assists with language skills and the ability to swallow. The physical therapist assists with ambulation and range of motion strengthening muscles. Both an electrocardiography (ECG) technician and an electroencephalogram (EMG) technician provide diagnostic testing, which provides data to plan care. Neither improve functioning.
A client is brought to the emergency department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other condition(s) is considered a neurologic deficit? Select all that apply.
- A. Impaired speech
- B. Abnormal bladder elimination
- C. Muscle strength
- D. Normal gait
- E. Paralysis
Correct Answer: A,B,E
Rationale: A neurologic deficit a condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent. Examples include paralysis, muscle weakness, impaired speech, inability to recognize objects, abnormal gait or difficulty walking, impaired memory, impaired swallowing, or abnormal bowel and bladder elimination.