Nokea
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.
You may also like to solve these questions
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 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 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.
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.
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.