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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.
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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.
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 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 caring for an 82-year-old client who needs bladder training. The nurse knows that bladder training is difficult for older adult clients with neurologic deficit because of what?
- A. Urinary incontinence
- B. Urinary retention
- C. Decreased energy expenditure
- D. Relaxation of the internal bladder sphincter
Correct Answer: D
Rationale: An age-related delay in the relaxation of the internal bladder sphincter may make bladder training difficult. Urinary incontinence, urinary retention, and decreased energy expenditure are not the factors that make bladder training difficult for older adult clients with neurologic deficit.
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.