Chapter 40: Caring for Pts w/ Neurological Deficits

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?

Perform duties professionally and explain that spontaneous erections are unpredictable.

Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public?

Sit beside client and patiently assist in interpreting communication.

A home health nurse is assisting the wheelchair-dependent, post-cerebrovascular accident client in transition from the rehabilitative center to home. Which of the following concerns would the nurse address first when assessing the client's home?

Steps to the front door

A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. 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

Use of a footboard

The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful?

When a client is attempting to empty the bladder

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?

"Grief is a normal process. Let's discuss offering support throughout the process."

What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit?

Help the client to the bathroom at a particular time each day.

The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states she has always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?

Ineffective Role Performance related to inability to function in family role

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?

Instill the enema slowly (1 to 2 oz at a time) followed by a waiting period.

The nurse is caring for clients on a neurologic floor. Which client goal is most appropriate for the acute phase of a neurologic injury?

The client's vital signs will stabilize returning to baseline.

The nurse is talking with a newly paralyzed client and his wife. The wife is trying to raise the client's spirits and begins talking about the possibility of them having a baby. When the wife is alone, which instruction in essential?

There is a reduced ability for your husband to be able to father children.

The home care nurse is evaluating a post-cerebrovascular accident (CVA) client 1 week after returning to the home from a rehabilitation setting. Which of the following statements, made by the client, most concerns the nurse?

"My spouse goes to work in the morning and leaves my lunch at my bed stand."

When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first?

A glycerin suppository

The nurse is assisting in the discharge process where a female, paralyzed client is returning home with her husband and two children. Which of the following prescription classifications, used prior to hospitalization, is most important to relate to the physician when discharging?

Birth control pills

The nurse is caring for a client with dysphagia. Which instruction to the family is most important?

Do not open/crush a medication in a capsule.

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 conditions are considered neurologic deficits? Select all that apply

Impaired speech Abnormal bladder elimination Paralysis

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?

Include client in planning of care and setting of goals.

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?

Lightly massage or tap the skin above the pubic area

Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply.

Maintaining body alignment promotes circulation Maintaining body alignment decreases pain

Which of the following assessment tools should the nurse use to perform a neurologic assessment?

Mini-Mental Status Examination

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply.

Occupational therapist Speech therapist Neurologist Physical therapist

In which of the following disease processes is the nurse most likely to care for a client in the chronic phase of a neurologic disease?

Parkinson's disease

The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focus on what?

Preventing physical and psychological complications

Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?

Prevention of joint contractures

A client with a neurologic deficit has been admitted to your 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?

Report the change to the physician.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it.

What phase of a neurologic deficit begins when the client's condition is stabilized?

Recovery

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapy should the nurse suggest to help strengthen muscles that are under voluntary control?

Occupational therapy

The nurse is caring for a client with neurologic deficits who is interested in implementing a bowel training program. Which of the following does the nurse identify as the first step?

Recording bowel movements

You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficit because of what?

Relaxation of the internal bladder sphincter

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?

"The client may be experiencing a change in affect due to the brain injury."

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?

Ensure a clutter-free walkway.

An emergency department nurse is admitting a client brought in by the paramedics after falling from a tree stand. The client has fractured vertebrae at T3 and T4. The nurse knows the client is in the acute phase of neurologic deficit. What should the nurse know about the medical management of this client?

Goal is to stabilize the client and prevent further neurologic damage.