Chapter 40: Caring for Clients With Neurologic Deficits

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 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."

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 condition(s) is considered a neurologic deficit? Select all that apply.

-Impaired speech -Abnormal bladder elimination -Paralysis

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

-Occupational therapist -Speech therapist -Physical therapist

A nurse is caring for a client with slight expressive aphasia. Which nursing technique(s) facilitates communication with the client? Select all that apply.

-Offer a communication board. -Allow time for the client to respond to questions -Guess words the client has difficulty saying and confirm understanding with the client.

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 mini 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 appropriate for the acute phase of a neurologic injury?

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

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?

Use of a footboard

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?

Alzheimer disease

The nurse is performing discharge teaching for a female client who was hospitalized after a spinal cord injury that resulted in motor paralysis. Which of the following prescription classifications, used prior to hospitalization, is most important to review with the client before discharge?

An oral contraceptive

A nurse is caring for a client who has a neurologic deficit. What would the nurse do to assist this client in increasing peristalsis and encouraging defecation?

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

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

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?

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

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?

Occupational therapy

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.

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?

Preventing physical and psychological complications

A nurse is caring for a client who has had a debilitating cerebrovascular accident. Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of this client?

Prevention of joint contractures

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?

Relaxation of the internal bladder sphincter

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?

Report the change to the physician.

A nurse is assisting a client with a neurologic deficit with bowel training. Which pharmacologic aid would the nurse anticipate to be used first?

Stool softener

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?

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

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

When a client is attempting to empty the bladder

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.

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?

Recording bowel movements

A nurse is caring for a client with a neurologic deficit whose condition has stabilized. What phase of the neurologic deficit begins now?

Recovery