Chapter 40 Neurologic Deficits

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 is the recovery phase?

Begins when the client's condition is stabilized and starts several days or weeks after the initial event and lasts weeks or months.

Dysarthria

Difficulty using the tongue, lips, palate, vocal cords, larynx, or breathing to produce speech.

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.

What is medical management for the chronic phase?

Physical and psychological rehabilitation to prevent complications, such as pressure ulcers and muscle contractures.

What is the main focus for medical management for the acute phase?

Stabilize the client and prevent further neurologic damage.

Expressive aphasia

The inability to produce language, but may be able to write information.

Receptive aphasia

The inability to understand spoken or written language, but may retain the ability to understand very common words.

Why is it important for a paralyzed client to take birth control pills?

They will continue to ovulate and can become pregnant.

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 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."

Neurologic deficit

A condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent.

What are examples of clients who are in the chronic phase?

Amyotrophic lateral sclerosis (ALS) also know as Lou Gehrig's disease or Alzheimer's disease.

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

What is medical management for the recovery phase?

Keeping the client stable and preventing or treating complications, such as pneumonia, and further neurologic impairment.

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.

What neurological tool does the nurse use as an assessment to check neurologic?

Mini-Mental Status Examination

What is the chronic phase?

Neurologic deficits result in a prolonged or lifelong phase. The client shows little or no improvement, remains stationary, or worsens.

What are examples of neurologic deficits?

Paralysis, muscle weakness, impaired speech, inability to recognize objects, abnormal gait or difficulty walking, impaired memory, impaired swallowing, or abnormal bowel and bladder elimination.

What is important for a nurse to implement while helping the client adapt to a change in functional status and teach about support programs?

Reassurance and emotional support: sit by the bed and patiently listen and assist with communication.

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.

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.

What is the acute phase?

Sudden neurologic event, such as a CVA or a head or spinal cord injury.

What is the point of rehabilitation?

To prevent complications and include client in the planning of care and setting goals.