Nokea
The nurse is caring for clients on a neurologic floor. Which client goal is appropriate for the acute phase of a neurologic injury?
- A. The client will use the adaptive devices to assist with feeding.
- B. The client's vital signs will stabilize returning to baseline.
- C. The client's skin will remain clean, dry, and intact.
- D. The client will return to optimal level of functioning.
Correct Answer: B
Rationale: During the acute phase of a neurologic injury, the goal of nursing management is to stabilize the client to prevent further neurologic damage. A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to baseline. Using adaptive devices would occur in the recovery or chronic phase of a neurologic deficit. The client's skin and returning to optimal level of functioning is a goal for later in the recovery process.
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The nurse is instructing the paralyzed client on a method to stimulate the relaxation of the urinary sphincter aiding in urinary elimination. Which instruction would be correct?
- A. Lightly massage or tap the skin above the pubic area.
- B. Press directly over the urinary bladder.
- C. Bear down increasing abdominal pressure.
- D. Pour water over the genitals.
Correct Answer: A
Rationale: Cutaneous triggering performed by massaging or tapping lightly over the pubic area stimulates relaxation of the urinary sphincter. Pressing over the urinary bladder is a component of the Cred?© maneuver, which does not relax the urinary sphincter. Bearing down with mouth and nose shut is a component to the Valsalva maneuver. Pouring water over the genitals is ineffective in a paralyzed client.
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.
A nurse is caring for a client who has had a debilitating cerebrovascular accident. Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of this client?
- A. Prevention of joint contractures
- B. Promoting ability to critically think
- C. Creating a positive environment
- D. Use of adaptive equipment
Correct Answer: A
Rationale: Though it is first addressed in the acute phase, the prevention of joint contractures is most helpful in promoting the rehabilitation of this client. The nursing care provided at an early period can prevent further complications in the rehabilitative phase. Promoting the ability to think critically is not a priority in the acute phase. Creating a positive environment is helpful in motivating the client. Using adaptive equipment is not a focus in the acute phase of the disease process.
The nurse is instructing the client on how to perform Cred?© maneuver. In which situation is this maneuver helpful?
- A. When a client is experiencing a vagal response during a bowel movement
- B. When a client is experiencing orthostatic hypotension upon arising
- C. When a client is attempting to empty the bladder
- D. When a client is experiencing numbness of the lower extremities
Correct Answer: C
Rationale: Cred?©'s maneuver is intended to increase abdominal pressure and facilitate the emptying of the bladder. The nurse instructs the client to bend at the waist or press inward and downward over the bladder. The other options are not correct.
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.