Nokea
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.
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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 performing discharge teaching for a female client who was hospitalized after a spinal cord injury that resulted in motor paralysis. Which of the following prescription classifications, used prior to hospitalization, is most important to review with the client before discharge?
- A. An oral contraceptive
- B. A nonsteroidal anti-inflammatory
- C. An analgesic
- D. An antihistamine
Correct Answer: A
Rationale: Motor paralysis does not affect ovulation. It is important for the nurse to review the need for continued contraceptive use with the client if a pregnancy is still undesired. A nonsteroidal anti-inflammatory, an analgesic, and an antihistamine used prior to the spinal cord injury may be reviewed prior to discharge but are lower priority.
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 slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.
- A. Offer a communication board.
- B. Encourage exercises such as whistling.
- C. Allow time for the client to respond to questions.
- D. Guess words the client has difficulty saying and confirm understanding with the client.
- E. Provide sensory aids.
Correct Answer: A,C,D
Rationale: The nurse should offer a communication board to the client, allow time for the client to respond to questions, and guess words the client has difficulty saying and confirm understanding with the client. Encouraging exercises such as whistling are appropriate for a client with dysarthria, not expressive aphasia. Providing sensory aids such as glasses is a technique appropriate for a client with receptive aphasia, not expressive aphasia.
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.