Nokea
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.
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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.
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 caring for a client diagnosed with neurologic deficit who has recently become responsive when interacted with. What therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
- A. Occupational therapy
- B. Range-of-motion (ROM) exercises
- C. Recreational therapy
- D. Music Therapy
Correct Answer: A
Rationale: Occupational therapy is designed to help strengthen muscles that are under voluntary control. ROM exercises maintain joint flexibility and prevent permanent contractures. Participation in recreational and music therapies increases socialization time.
A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
- A. Use the Glasgow Coma Scale.
- B. Use the Mini-Mental Status Examination.
- C. Report the change to the physician.
- D. Monitor the blood pressure.
Correct Answer: C
Rationale: When significant changes occur, the nurse should immediately report them to the physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools, such as the Mini-Mental Status Examination, to perform the neurologic assessments to evaluate the client's status. The nurse maintains the blood pressure to ensure adequate cerebral oxygenation.
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.