Nokea
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.
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An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?
- A. Goal is to keep the client stable and prevent or treat complications, such as pneumonia, and further neurologic impairment.
- B. Goal is to plan a rehabilitation program in several domains according to the client's abilities and limitations.
- C. Goal is to admit the client to a hospital for treatment of complications.
- D. Goal is to stabilize the client and prevent further neurologic damage.
Correct Answer: D
Rationale: The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage. The client with a CVA may require management of hypertension or hypotension through drug therapy. The client with a head or spinal cord injury may require respiratory support through mechanical ventilation or surgical intervention to stabilize the injured area or remove bone fragments, blood clots, or foreign objects. Sometimes, surgery is postponed until the client is stabilized and the acute phase has passed. In other instances, surgery is performed during the acute phase as a lifesaving measure. Keeping the client stable and preventing or treating complications is the aim of medical management of the recovery phase. Planning a rehabilitation program according to the client abilities and limitations and admit the client for treatment of complications are nursing goals, not medical goals for different phases of neurologic deficit.
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.
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 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.
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client indicates that the client is assuming independence?
- A. The client grasps the affected arm at the wrist and raises it.
- B. The client arranges a community service to deliver meals.
- C. The clientmu client ambulates with the assistance of one.
- D. The client uses a mechanical lift to climb steps.
Correct Answer: A
Rationale: The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.