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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.
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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.
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.
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.
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.