Nokea
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.
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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.
A nurse has just received a new client and is preparing to perform a neurologic assessment. Which of the following assessment tools should the nurse use?
- A. Cutaneous triggering
- B. Mini-Mental Status Examination
- C. Cred?©'s maneuver
- D. Mechanical lift
Correct Answer: B
Rationale: The nurse uses assessment tools such as the Mini-Mental Status Examination to perform the neurologic assessment. Cutaneous triggering and Cred?©'s maneuver are techniques used in implanting a bladder training program. A mechanical lift is used to transfer a client to and from the bed, wheelchair, or shower.
The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which does the nurse identify as the first step?
- A. Obtaining a laxative
- B. Eating a select diet
- C. Recording bowel movements
- D. Providing privacy
Correct Answer: C
Rationale: The first step in implementing a bowel training program is identifying the body's typical bowel habits. By keeping a journal of bowel movements over weeks, the client is able to identify when a bowel movement is most likely to occur. All of the other options may be included in a bowel training program at a later stage.
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 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.