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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.
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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.
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.
The nurse is caring for a client with paraplegia in the acute care setting. The client's last bowel movement was 4 days ago. Which nursing action is best to assist the client in accomplishing the goal of an enema?
- A. Tape the client's buttocks together so to retain the enema.
- B. Instill the mini enema slowly (1 to 2 oz at a time) followed by a waiting period.
- C. Prop the client over a toilet to allow gravity to assist in the defecation process.
- D. Insert the enema tubing high into the bowel to increase fecal mass elimination.
Correct Answer: B
Rationale: The best nursing action is to instill the enema solution slowly and allow a waiting period. By doing so, the enema solution has the best opportunity to be effective. The nurse would tape the buttocks together when administering a suppository. Propping the client over the toilet would allow the enema solution to be expelled immediately. Enema tubing is inserted carefully into the rectum and not advanced high into the colon.
The nurse is caring for a client in the chronic phase of a neurologic deficit. The nurse knows that nursing management in this phase focuses on what?
- A. Working with team members to plan a rehabilitation program
- B. Retraining the client's bowel and bladder
- C. Supporting the client during recovery
- D. Preventing physical and psychological complications
Correct Answer: D
Rationale: Nursing management of clients in the chronic phase of a neurologic deficit focuses on preventing physical and psychological complications. Planning a rehabilitation program occurs during the recovery phase, as would retraining the client's bowel and bladder, if possible, and supporting the client's recovery.
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.