Nokea
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.
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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.
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.
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 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 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.