Chapter 40: Caring for Clients with Neurologic Deficits
A patient has left-sided hemiplegia as the result of a brain attack (cerebrovascular accident). While being dressed, the patient states in a disgusted tone of voice, "I feel like a 2-year-old. I can't even get dressed by myself." What is the nurse's best response? "You are feeling down today, but things will get better." "It's hard to feel dependent on others." "Most people who have had a stroke feel this way." "It must be terrible not being able to move your arm."
"It's hard to feel dependent on others." Explanation: The nurse should identify the patient's feelings and provide opportunity for further discussion. Grief is a normal response to loss. Generalization is not helpful and may not be accurate; also, it cuts off communication. Statements that focus on the inability to move rather than feelings of helplessness, dependence, and regression are not productive. Stating that "...things will get better" is false reassurance because the nurse does not know if things will get better.
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? "A lot of family is coming to see me, which is nice but makes me very tired." "I find it difficult to get up so I am remaining in bed until the home health aide comes." "My spouse goes to work in the morning and leaves my lunch at my bed stand." "I am so happy to be home, but I am not able to go upstairs to my bedroom."
"My spouse goes to work in the morning and leaves my lunch at my bed stand." Explanation: The nurse analyzes the statements and compares them to Maslow's hierarchy of needs. Leaving the lunch at the bed stand alludes to the fact that the client is alone during the day and either stays in bed or is unable physically to obtain lunch from the kitchen. Being in bed for an extended period is a concern for skin breakdown, and if the client is physically weak, safety is a concern. Living arrangements can be made downstairs. Waiting for a home health aide for assistance is appropriate as long as those arrangements are made. Tiring the client with family visits is a concern but not a safety issue.
The nurse assists a team of providers in the recovery phase for a client with a neurologic deficit. A program of care will be outlined to meet immediate and long-term goals. Which interdisciplinary member(s) should be included in the client's nursing plan of care? Select all that apply. -nutritionist -physical therapist -occupational therapist -orthopedic surgeon -speech therapist
-nutritionist -speech therapist -physical therapist -occupational therapist Explanation: A successful rehabilitation program would include not only nurses and physicians but also several other providers, including physical therapists, occupational therapists, speech therapists, and enterostomal therapists. The client will meet with an occupational therapist to determine which adaptive devices will assist with eating and grooming. The client will meet with a nutritionist to address any nutritional deficiencies. The client will enroll in a physical therapy program as part of the rehabilitative process to address the client's movement needs. A speech therapist addresses any communication issues the client may experiences because of the neurologic deficit. Surgical intervention for a contracture would occur during the chronic phase of recovery; therefore, it is not appropriate for the nurse to include a surgeon in the client's nursing plan of care at this time.
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days It can be administered every 6 hours for 10 days. 2 hours prior to the administration of antibiotics for 7 days 1 hour after the antibiotic has infused and daily for 7 days
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Explanation: Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding (Bader & Littlejohns, 2010).
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? Call the rapid response team because the patient is preparing to arrest. Place the patient in the supine position. Administer atropine to control the side effects of edrophonium. Administer diphenhydramine (Benadryl) for the allergic reaction.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Administer atropine to control the side effects of edrophonium. -Call the rapid response team because the patient is preparing to arrest. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Place the patient in the supine position.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Call the rapid response team because the patient is preparing to arrest. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Administer atropine to control the side effects of edrophonium. -Place the patient in the supine position.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Place the patient in the supine position. -Administer atropine to control the side effects of edrophonium. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Call the rapid response team because the patient is preparing to arrest.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Place the patient in the supine position. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Administer atropine to control the side effects of edrophonium. -Call the rapid response team because the patient is preparing to arrest.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? -Place the patient in the supine position. -Administer diphenhydramine (Benadryl) for the allergic reaction. -Call the rapid response team because the patient is preparing to arrest. -Administer atropine to control the side effects of edrophonium.
Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? -Decreased muscle spasms in the lower extremities -Increased muscle strength in the upper extremities -Reduction in the appearance of new lesions on the MRI -Decreased severity and duration of exacerbations
Decreased muscle spasms in the lower extremities Explanation: Baclofen, a γ-aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities.
A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? -Decreased severity and duration of exacerbations -Reduction in the appearance of new lesions on the MRI -Decreased muscle spasms in the lower extremities -Increased muscle strength in the upper extremities
Decreased muscle spasms in the lower extremities Explanation: Baclofen, a γ-aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities.
A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? EEG CT Cerebral angiography ABG analysis
EEG Explanation: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD.
A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? -CT -ABG analysis -EEG -Cerebral angiography
EEG Explanation: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD.
A 25-year-old client with brain metastases is considering life expectancy after their most recent meeting with the oncologist. Since the client is not receiving treatment for the brain metastases, what is the nurse's priority action? Promoting the client's functional status and activities of daily living (ADLs) Ensuring that the client receives adequate palliative care Promoting adherence to the prescribed medication regimen Ensuring that the family does not tell the client that the condition is terminal
Ensuring that the client receives adequate palliative care Explanation: Clients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the client. Adherence to medications such as analgesics is important, but palliative care is a high priority.
A 25-year-old client with brain metastases is considering life expectancy after their most recent meeting with the oncologist. Since the client is not receiving treatment for the brain metastases, what is the nurse's priority action? Promoting the client's functional status and activities of daily living (ADLs) Ensuring that the family does not tell the client that the condition is terminal Ensuring that the client receives adequate palliative care Promoting adherence to the prescribed medication regimen
Ensuring that the client receives adequate palliative care Explanation: Clients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the client. Adherence to medications such as analgesics is important, but palliative care is a high priority.
A 25-year-old client with brain metastases is considering life expectancy after their most recent meeting with the oncologist. Since the client is not receiving treatment for the brain metastases, what is the nurse's priority action? Promoting the client's functional status and activities of daily living (ADLs) Ensuring that the family does not tell the client that the condition is terminal Promoting adherence to the prescribed medication regimen Ensuring that the client receives adequate palliative care
Ensuring that the client receives adequate palliative care Explanation: Clients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the client. Adherence to medications such as analgesics is important, but palliative care is a high priority.
A 25-year-old client with brain metastases is considering life expectancy after their most recent meeting with the oncologist. Since the client is not receiving treatment for the brain metastases, what is the nurse's priority action? Promoting adherence to the prescribed medication regimen Promoting the client's functional status and activities of daily living (ADLs) Ensuring that the client receives adequate palliative care Ensuring that the family does not tell the client that the condition is terminal
Ensuring that the client receives adequate palliative care Explanation: Clients with intracerebral metastases who are not treated have a steady downhill course with a limited survival time, whereas those who are treated may survive for slightly longer periods, but for most cure is not possible. Palliative care is thus necessary. This is a priority over promotion of function and the family should not normally withhold information from the client. Adherence to medications such as analgesics is important, but palliative care is a high priority.
A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? -Avoid foods that change the pH of urine. -Establish a timed voiding schedule. -Administer anticholinergic drugs as prescribed. -Perform intermittent catheterization q6h.
Establish a timed voiding schedule. Explanation: A timed voiding schedule addresses many of the challenges with urinary continence that face the client with MS. Interventions should be implemented to prevent the need for catheterization and anticholinergics are not normally used.
A client with paralysis is disturbed by spontaneous erections. Which nursing action may help the client? -Suggest the use of a disposable porous pad. -Explain that it may occur when the bladder is full. -Perform passive ROM exercise. -Recommend medical assistance.
Explain that it may occur when the bladder is full. Explanation: Explain to the client that spontaneous erections may occur when the bladder is full. Spontaneous erections are unpredictable and sometimes circumstantially inconvenient.
A nurse is reviewing a client's medical record and finds that the client has a spinal cord tumor that involves the vertebral bodies. The nurse identifies this as which type of spinal tumor? Metastatic Intramedullary Extradural Intradural-extramedullary
Extradural Explanation: Tumors within the spine are classified according to their anatomic relation to the spinal cord. Intramedullary tumors arise from within the spinal cord. Intradural-extramedullary tumors are within or under the spinal dura but not on the actual spinal cord. Extradural tumors are located outside the dura and often involve the vertebral bodies.
The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? Respiratory depression Labile BP Falls Audio hallucinations
Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.
The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? -Audio hallucinations -Falls -Respiratory depression -Labile BP
Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.
The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? -Audio hallucinations -Labile BP -Respiratory depression -Falls
Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.
The nurse is planning the care of a client who has been recently diagnosed with a cerebellar tumor. Due to the location of this client's tumor, the nurse should implement measures to prevent what complication? -Respiratory depression -Audio hallucinations -Falls -Labile BP
Falls Explanation: A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, and marked muscle incoordination. Because of this, the client faces a high risk of falls. Hallucinations and unstable vital signs are not closely associated with cerebellar tumors.
A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? Identify the triggers that precipitated the seizure. Implement precautions to ensure the client's safety. Teach the client's family about the relationship between brain tumors and seizure activity. Ensure that the client is housed in a private room.
Implement precautions to ensure the client's safety. Explanation: Clients with seizures are carefully monitored and protected from injury. Client safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these are not the highest priority. A private room is preferable, but not absolutely necessary.
A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event? -Implement precautions to ensure the client's safety. -Ensure that the client is housed in a private room. -Teach the client's family about the relationship between brain tumors and seizure activity. -Identify the triggers that precipitated the seizure.
Implement precautions to ensure the client's safety. Explanation: Clients with seizures are carefully monitored and protected from injury. Client safety is a priority over health education, even though this is appropriate and necessary. Specific triggers may or may not be evident; identifying these are not the highest priority. A private room is preferable, but not absolutely necessary.
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? Elimination of distressing signs and symptoms Removal of all or part of the tumor Reduced incidence of recurrence Improved quality of life
Improved quality of life Explanation: The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both client and family. Removal of all or part of the tumor is the goal of surgery. Radiation therapy attempts to decrease the incidence of recurrence of incompletely resected tumors.
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? Reduced incidence of recurrence Elimination of distressing signs and symptoms Improved quality of life Removal of all or part of the tumor
Improved quality of life Explanation: The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both client and family. Removal of all or part of the tumor is the goal of surgery. Radiation therapy attempts to decrease the incidence of recurrence of incompletely resected tumors.
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? -Elimination of distressing signs and symptoms -Reduced incidence of recurrence -Removal of all or part of the tumor -Improved quality of life
Improved quality of life Explanation: The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both client and family. Removal of all or part of the tumor is the goal of surgery. Radiation therapy attempts to decrease the incidence of recurrence of incompletely resected tumors.
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? -Reduced incidence of recurrence -Improved quality of life -Removal of all or part of the tumor -Elimination of distressing signs and symptoms
Improved quality of life Explanation: The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both client and family. Removal of all or part of the tumor is the goal of surgery. Radiation therapy attempts to decrease the incidence of recurrence of incompletely resected tumors.
A nurse is providing care to a client who has been diagnosed with metastatic brain cancer. When developing the client's plan of care, which outcome would the nurse most likely identify? -Reduced incidence of recurrence -Removal of all or part of the tumor -Improved quality of life -Elimination of distressing signs and symptoms
Improved quality of life Explanation: The treatment of metastatic brain cancer is palliative and involves eliminating or reducing serious symptoms. Even when palliation is the goal, distressing signs and symptoms can be relieved, thereby improving the quality of life for both client and family. Removal of all or part of the tumor is the goal of surgery. Radiation therapy attempts to decrease the incidence of recurrence of incompletely resected tumors.
The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time? -In the morning -Immediately after meals -In the early evening -Before bedtime
In the morning Explanation: Important activities for clients with post-polio syndrome should be planned for the morning, as fatigue often increases in the afternoon and evening.
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? Deficient Diversional Activity related to the inability to participate in family activity Ineffective Role Performance related to inability to function in family role Impaired Home Maintenance related to inability to care for home setting Ineffective Coping related to refusing to acknowledge physical limitations
Ineffective Role Performance related to inability to function in family role Explanation: The nurse recognizes that the client is grieving the loss, whether temporary or permanent, of the role of caregiver in the family. The client also states not wanting to be a burden indicating a role reversal. The other options may also be relevant; however, they are not as closely related to the client's statement.
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 Coping related to refusing to acknowledge physical limitations Deficient Diversional Activity related to the inability to participate in family activity Ineffective Role Performance related to inability to function in family role Impaired Home Maintenance related to inability to care for home setting
Ineffective Role Performance related to inability to function in family role Explanation: The nurse recognizes that the client is grieving the loss, whether temporary or permanent, of the role of caregiver in the family. The client also states not wanting to be a burden indicating a role reversal. The other options may also be relevant; however, they are not as closely related to the client's statement.
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 Coping related to refusing to acknowledge physical limitations Ineffective Role Performance related to inability to function in family role Impaired Home Maintenance related to inability to care for home setting Deficient Diversional Activity related to the inability to participate in family activity
Ineffective Role Performance related to inability to function in family role Explanation: The nurse recognizes that the client is grieving the loss, whether temporary or permanent, of the role of caregiver in the family. The client also states not wanting to be a burden indicating a role reversal. The other options may also be relevant; however, they are not as closely related to the client's statement.
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Inform the surgeon of the possibility of a dural leak. Page the health care provider and report this sign of infection. Reposition the client to prevent further hemorrhage. Reinforce the dressing and reassess in 1 to 2 hours.
Inform the surgeon of the possibility of a dural leak. Explanation: After a cervical discectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Page the health care provider and report this sign of infection. Inform the surgeon of the possibility of a dural leak. Reinforce the dressing and reassess in 1 to 2 hours. Reposition the client to prevent further hemorrhage.
Inform the surgeon of the possibility of a dural leak. Explanation: After a cervical discectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Page the health care provider and report this sign of infection. Reposition the client to prevent further hemorrhage. Reinforce the dressing and reassess in 1 to 2 hours. Inform the surgeon of the possibility of a dural leak.
Inform the surgeon of the possibility of a dural leak. Explanation: After a cervical discectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Reinforce the dressing and reassess in 1 to 2 hours. Inform the surgeon of the possibility of a dural leak. Page the health care provider and report this sign of infection. Reposition the client to prevent further hemorrhage.
Inform the surgeon of the possibility of a dural leak. Explanation: After a cervical discectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.
While assessing the client at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the clients' cervical discectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurse's most appropriate action? Reinforce the dressing and reassess in 1 to 2 hours. Page the health care provider and report this sign of infection. Reposition the client to prevent further hemorrhage. Inform the surgeon of the possibility of a dural leak.
Inform the surgeon of the possibility of a dural leak. Explanation: After a cervical discectomy, the nurse will monitor the operative site and dressing covering this site. Serosanguineous drainage may indicate a dural leak. This constitutes a risk for meningitis, but is not a direct sign of infection. This should be reported to the surgeon, not just reinforced and observed.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? Assess for facial weakness. Initiate seizure precautions. Ensure that client takes nothing by mouth. Assess visual acuity.
Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? Assess visual acuity. Assess for facial weakness. Ensure that client takes nothing by mouth. Initiate seizure precautions.
Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? -Assess for facial weakness. -Initiate seizure precautions. -Ensure that client takes nothing by mouth. -Assess visual acuity.
Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? -Initiate seizure precautions. -Ensure that client takes nothing by mouth. -Assess for facial weakness. -Assess visual acuity.
Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan? -Knowledge deficit -Body image disturbance -Anxiety -Impaired cognition
Knowledge deficit Explanation: Clients with extensive neurologic deficits before surgery usually do not make significant functional recovery, even after successful tumor removal. In this case, the client had already developed bilateral sensory loss in the lower extremities indicating the fairly progressed impact of the tumor on the client's functional ability. The client's statement reflects a knowledge deficit and it is a priority to provide information regarding the possibility that lower extremity sensation may not return. Although body image disturbance and anxiety may be identified and addressed. This would occur after the client demonstrates an accurate understanding of loss of functional capabilities as a result of the progressed tumor. Ensuring the client understands the extent of functional loss due to the impact of the tumor is a priority. The client does not demonstrate impaired cognition.
The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? Sensory perception Peripheral pulses Level of consciousness Crackles bilaterally
Level of consciousness Explanation: As the abscess expands, symptoms of increased intracranial pressure such as decreasing level of consciousness and seizures occur. Ongoing neurologic assessment alerts the nurse to changes in intracranial pressure, which may indicate a need for more aggressive intervention.
The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? -Level of consciousness -Peripheral pulses -Crackles bilaterally -Sensory perception
Level of consciousness Explanation: As the abscess expands, symptoms of increased intracranial pressure such as decreasing level of consciousness and seizures occur. Ongoing neurologic assessment alerts the nurse to changes in intracranial pressure, which may indicate a need for more aggressive intervention.
The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? -Sensory perception -Peripheral pulses -Crackles bilaterally -Level of consciousness
Level of consciousness Explanation: As the abscess expands, symptoms of increased intracranial pressure such as decreasing level of consciousness and seizures occur. Ongoing neurologic assessment alerts the nurse to changes in intracranial pressure, which may indicate a need for more aggressive intervention.
A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? -Loss of hearing, tinnitus, and vertigo -Loss of hearing, increased sodium retention, and hypertension -Loss of vision, headache, and tachycardia -Loss of vision, change in mental status, and hyperthermia
Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.
A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? -Loss of vision, headache, and tachycardia -Loss of hearing, increased sodium retention, and hypertension -Loss of hearing, tinnitus, and vertigo -Loss of vision, change in mental status, and hyperthermia
Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.
A nurse is assessing a client with an acoustic neuroma who has been recently admitted to an oncology unit. What symptoms is the nurse likely to find during the initial assessment? -Loss of vision, headache, and tachycardia -Loss of vision, change in mental status, and hyperthermia -Loss of hearing, increased sodium retention, and hypertension -Loss of hearing, tinnitus, and vertigo
Loss of hearing, tinnitus, and vertigo Explanation: An acoustic neuroma is a tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance. The client with an acoustic neuroma usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait. Acoustic neuromas do not cause loss of vision, increased sodium retention, or tachycardia.
A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? -Many older adults are hesitant to admit that their body is changing. -Many symptoms can be the result of normal aging process. -Older adults have fewer peripheral nerves than younger adults. -Older adults are often vague historians.
Many symptoms can be the result of normal aging process. Explanation: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the client has come to the clinic seeking help for this problem; this does not indicate a desire on the part of the client to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves.
A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? -Many symptoms can be the result of normal aging process. -Older adults have fewer peripheral nerves than younger adults. -Older adults are often vague historians. -Many older adults are hesitant to admit that their body is changing.
Many symptoms can be the result of normal aging process. Explanation: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the client has come to the clinic seeking help for this problem; this does not indicate a desire on the part of the client to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves.
The nurse is caring for a boy who has muscular dystrophy. When planning assistance with the client's ADLs, what goal should the nurse prioritize? -Fostering the family's participation in care -Promoting the client's recovery from the disease -Maximizing the client's level of function -Ensuring the client's adherence to treatment
Maximizing the client's level of function Explanation: Priority for the care of the child with muscular dystrophy is the need to maximize the client's level of function. Family participation is also important, but should be guided by this goal. Adherence is not a central goal, even though it is highly beneficial, and the disease is not curable.
The nurse educator is facilitating a class on neurological function with a group of nursing students. When discussing problems that can result from growing brain tumors, the nurse educator should include that clients can experience which neurologic deficits even after surgical resection? Select all that apply. Aphasia Incontinence Fever Respiratory infection Paralysis
Paralysis Incontinence Aphasia Explanation: Although fever and respiratory infection can result from various factors that influence the hospitalized client, these are not categorized as neurologic deficits. The nurse educator is correct in stating that paralysis, incontinence and aphasia are potential neurological deficits that can result from pressure of growing tumors on surrounding brain structures. The arise from a decreased sensory motor response of the central and peripheral nervous system.
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? -Integumentary -Hepatic -Musculoskeletal -Renal
Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? Avoiding naps during the day Increasing the dose of muscle relaxants Taking a hot bath at least once daily Resting in an air-conditioned room whenever possible
Resting in an air-conditioned room whenever possible Explanation: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? -Resting in an air-conditioned room whenever possible -Avoiding naps during the day -Increasing the dose of muscle relaxants -Taking a hot bath at least once daily
Resting in an air-conditioned room whenever possible Explanation: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? -Taking a hot bath at least once daily -Resting in an air-conditioned room whenever possible -Increasing the dose of muscle relaxants -Avoiding naps during the day
Resting in an air-conditioned room whenever possible Explanation: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.
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 Untrained companion staying with client Tub for bathing Throw rugs in the kitchen
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? Untrained companion staying with client Tub for bathing Steps to the front door Throw rugs in the kitchen
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? -Throw rugs in the kitchen -Untrained companion staying with client -Steps to the front door -Tub for bathing
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? -Tub for bathing -Steps to the front door -Throw rugs in the kitchen -Untrained companion staying with client
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? -Tub for bathing -Throw rugs in the kitchen -Steps to the front door -Untrained companion staying with client
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? -Tub for bathing -Untrained companion staying with client -Throw rugs in the kitchen -Steps to the front door
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
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? -Untrained companion staying with client -Tub for bathing -Steps to the front door -Throw rugs in the kitchen
Steps to the front door Explanation: The first obstacle for a wheelchair-dependent client is getting into the home. A ramp is needed to transport the client from the vehicle to the inside of the home as well as safety for leaving the home. Throw rugs can be removed and adaptive equipment can be obtained for personal care. Untrained staff may be appropriate for brief periods of time.
A client diagnosed with a malignant brain tumor is scheduled to receive chemotherapy intrathecally. When explaining this technique to the client, the nurse would describe the medication as being injected into which area? -Central vein -Subarachnoid space -Implanted port -Epidural space
Subarachnoid space Explanation: Chemotherapy given intrathecally is injected directly into the subarachnoid space, not a central vein, implanted port or epidural space.
A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? Gradual improvement over several months Symptom improvement that lasts a few weeks after TPE ceases Permanent improvement after 60 to 90 treatments Permanent improvement after 4 to 6 months of treatment
Symptom improvement that lasts a few weeks after TPE ceases Explanation: Symptoms improve in 75% of clients undergoing TPE; however, improvement lasts only a few weeks after treatment is completed.
A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? -Gradual improvement over several months -Permanent improvement after 60 to 90 treatments -Symptom improvement that lasts a few weeks after TPE ceases -Permanent improvement after 4 to 6 months of treatment
Symptom improvement that lasts a few weeks after TPE ceases Explanation: Symptoms improve in 75% of clients undergoing TPE; however, improvement lasts only a few weeks after treatment is completed.
During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)? The Barthel Index Hamilton Assessment Scale The National Institute for Health Stroke Scale The American Heart Association's Stroke Outcome Classification
The Barthel Index Explanation: On The Barthel Index, each performance ADL item is rated with a given number of points assigned to each level or ranking. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? Brain tumors in older adults do not normally produce focal effects. Older adults typically have numerous benign brain tumors by the eighth decade of life. Brain tumors cannot normally be treated in clients over age 75. The effects of brain tumors are often attributed to the cognitive effects of aging.
The effects of brain tumors are often attributed to the cognitive effects of aging. Explanation: In older adult clients, early signs and symptoms of intracranial tumors can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Brain tumors are not normally benign and they produce focal effects in all clients. Treatment options are not dependent primarily on age.
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults? The effects of brain tumors are often attributed to the cognitive effects of aging. Brain tumors in older adults do not normally produce focal effects. Older adults typically have numerous benign brain tumors by the eighth decade of life. Brain tumors cannot normally be treated in clients over age 75.
The effects of brain tumors are often attributed to the cognitive effects of aging. Explanation: In older adult clients, early signs and symptoms of intracranial tumors can be easily overlooked or incorrectly attributed to cognitive and neurologic changes associated with normal aging. Brain tumors are not normally benign and they produce focal effects in all clients. Treatment options are not dependent primarily on age.
A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? Whether the tumor utilizes aerobic or anaerobic respiration The specific hormones secreted by the tumor The client's pre-existing health status Whether the tumor is primary or the result of metastasis
The specific hormones secreted by the tumor Explanation: Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary and the effects of the tumor depend largely on the identity of these hormones. This variable is more significant than the client's health status or whether the tumor is primary versus secondary. Anaerobic and aerobic respiration are not relevant.
A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? -Whether the tumor is primary or the result of metastasis -The client's pre-existing health status -The specific hormones secreted by the tumor -Whether the tumor utilizes aerobic or anaerobic respiration
The specific hormones secreted by the tumor Explanation: Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary and the effects of the tumor depend largely on the identity of these hormones. This variable is more significant than the client's health status or whether the tumor is primary versus secondary. Anaerobic and aerobic respiration are not relevant.
A client diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the client's care, the nurse should be aware that the effects of the tumor will primarily depend on what variable? -Whether the tumor is primary or the result of metastasis -The client's pre-existing health status -Whether the tumor utilizes aerobic or anaerobic respiration -The specific hormones secreted by the tumor
The specific hormones secreted by the tumor Explanation: Functioning pituitary tumors can produce one or more hormones normally produced by the anterior pituitary and the effects of the tumor depend largely on the identity of these hormones. This variable is more significant than the client's health status or whether the tumor is primary versus secondary. Anaerobic and aerobic respiration are not relevant.
The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? Intermittent hearing loss Tinnitus Tongue enlargement Vocal paralysis
Vocal paralysis Explanation: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease.
The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? -Vocal paralysis -Intermittent hearing loss -Tongue enlargement -Tinnitus
Vocal paralysis Explanation: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease.
A critically ill client is being treated for signs and symptoms of altered level of consciousness (LOC), hypertension, fever, and difficulty in breathing. Which phase of neurologic deficit is the client experiencing? -chronic -irreversible -acute -recovery
acute Explanation: During the acute phase, the client usually is critically ill with many signs and symptoms such as altered LOC, hypertension or hypotension, fever, difficulty in breathing, or paralysis.
A neurologic deficit is best defined as a deficit of the: -central and peripheral nervous systems with decreased, impaired, or absent functioning. -peripheral nervous system with decreased or impaired functioning. -central nervous system with absent functioning. -central nervous system that affects one body system.
central and peripheral nervous systems with decreased, impaired, or absent functioning. Explanation: A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.
A neurologic deficit is best defined as a deficit of the: -central nervous system with absent functioning. -central and peripheral nervous systems with decreased, impaired, or absent functioning. -peripheral nervous system with decreased or impaired functioning. -central nervous system that affects one body system.
central and peripheral nervous systems with decreased, impaired, or absent functioning. Explanation: A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: choking. falls. infection. complications.
complications. Explanation: Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: falls. infection. complications. choking.
complications. Explanation: Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? -immediately -in 2 to 3 days -upon transfer to a rehabilitation unit -after 1 week
immediately Explanation: Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? -in 2 to 3 days -after 1 week -immediately -upon transfer to a rehabilitation unit
immediately Explanation: Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? assessing vital signs frequently preventing further neurologic damage destabilizing client's condition reporting changes to the physician
preventing further neurologic damage Explanation: The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? -destabilizing client's condition -reporting changes to the physician -assessing vital signs frequently -preventing further neurologic damage
preventing further neurologic damage Explanation: The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? -preventing further neurologic damage -assessing vital signs frequently -reporting changes to the physician -destabilizing client's condition
preventing further neurologic damage Explanation: The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? home care nurse chaplain physical therapist spouse
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? -chaplain -physical therapist -spouse -home care nurse
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? -physical therapist -chaplain -spouse -home care nurse
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? -physical therapist -home care nurse -chaplain -spouse
spouse Explanation: The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? -ice cream -vegetables -meat -white rice
vegetables Explanation: Vegetables are high in fiber. Fiber increases fecal bulk and pulls water into the feces, promoting regular bowel movements. Ice cream, meat, and white rice are low in fiber.
