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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.
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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.
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 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.
The nurse is providing care to a client with neurologic problems and notices that the client is experiencing a penile erection. Which nursing reaction is correct?
- A. Excuse oneself and return later.
- B. Inquire what the client is thinking about.
- C. Ask if the client would like a few minutes alone.
- D. Perform duties professionally and explain that spontaneous erections are unpredictable.
Correct Answer: D
Rationale: The nurse understands that the client with neurologic deficits, especially disturbed nerve function to the genitalia, may have unpredictable penile erections. The correct action by the nurse is to complete nursing duties and, either then or later, explain that spontaneous erections are unpredictable. Excusing oneself, inquiring what the client is thinking about, and asking if the client would like to be alone are inappropriate statements and can alienate and embarrass the client.
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.