Nokea
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.
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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.
A nursing instructor is teaching the senior nursing class about clients with neurologic disorders. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?
- A. Use of parallel bars or a walker
- B. Application of an abdominal binder
- C. Use of a footboard
- D. Use of a flotation mattress
Correct Answer: C
Rationale: A footboard positions the foot and ankle in such a way as to prevent plantar flexion. Parallel bars help the client with impaired mobility to support body weight and move forward before ambulating independently. An abdominal binder prevents dizziness and faintness. A flotation mattress helps relieve pressure when the client is lying down and sitting.
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.
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.
The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, 'I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?' The nurse is most helpful to say which of the following?
- A. There is nothing you can do. It must come from the client.
- B. Grief is a normal process. Let's discuss offering support throughout the process.
- C. Ask your loved one what you can do and decorate the room to elevate mood.
- D. Provide comfort foods to express your love and support.
Correct Answer: B
Rationale: The best response by the nurse is to confirm that what the client is experiencing is a normal process and opening conversation. The nurse is also helpful to identify the upcoming process that the client will be experiencing. Stating that there is nothing that the family member can do closes communication and is inaccurate. The other responses may be helpful but are not the best.