Neurologic Deficits
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? A) Prevention of joint contractures B) Promoting ability to critically think C) Creating a positive environment D) Use of adaptive equipment
A First addressed in the acute phase, however, impacting the rehabilitative process is the prevention of joint contractures. The nursing care provided at an early period can prevent further complications in the rehabilitative phase. Promoting the ability to critically think is not a priority in the acute phase. Creating a positive environment is helpful in motivating the client. Using adaptive equipment is not a focus in the acute phase of the disease process
What would the nurse do to best assist the client in increasing peristalsis and encouraging defecation after suffering from a neurologic deficit? A) Help the client to the bathroom at a particular time each day. B) Administer a low-volume enema each day at the same time. C) Encourage liquids throughout the day. D) Encourage a high-fiber diet.
A Helping the client to the bathroom at a particular time each day increases peristalsis and encourages defecation because of the physical activity involved in getting out of bed. Administering a low-volume enema stimulates a bowel movement. Increase in fluid intake and a high-fiber diet will aid in normalizing bowel movements.
The nurse is caring for a client with dysphagia. Which instruction to the family is most important? A) Do not open/crush a medication in a capsule. B) Stir thickening products in liquids and serve immediately. C) Raise client to a semi-Fowler's position. D) Provide small bites at the client's pace
A Providing instruction to the family to not open or crush medications in a capsule is most important for safety. A client can receive too much medication if the capsule is opened and the contents distributed. The other options are good teaching points, but safety is most important.
Which of the following assessment tools should the nurse use to perform a neurologic assessment? A) Cutaneous triggering B) Mini-Mental Status Examination C) Credé's maneuver D) Mechanical lift
B The nurse uses assessment tools such as the Mini-Mental Status Examination to perform the neurologic assessment. Cutaneous triggering and Credé's maneuver are techniques used in implanting a bladder training program. A mechanical lift is used to transfer a client to and from the bed, wheelchair, or shower
Which nursing technique best allows the client with slight expressive aphasia to communicate his feelings about using adaptive equipment in public? A) Use a communication board to express thoughts. B) Enlist a close family member to interpret words. C) Sit beside client and patiently assist in interpreting communication. D) Allow the client time to process the words to express and return later for the conversation.
C A client with slight expressive aphasia can communicate words and ideas with sufficient time and patience on the part of the person listening. Sitting beside the client is nonthreatening and working with the client to express his ideas is gratifying to the client. If the client is able to do something for himself, it is best to allow time and assist him in the task. With further expressive aphasia, a communication board may be used or a family member may assist. Rarely does allowing time to process words and returning promote communication
The nurse is instructing the client on how to perform Credé's maneuver. In which situation is this maneuver helpful? A) When a client is experiencing a vagal response during a bowel movement B) When a client is experiencing orthostatic hypotension upon arising C) When a client is attempting to empty the bladder D) When a client is experiencing numbness of the lower extremities
C Credé's maneuver is intended to increase abdominal pressure and facilitates the emptying of the bladder. The nurse instructs the client to bend at the waist or press inward and downward over the bladder. The other options are not correct.
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? A) Continue to talk about a baby as it seems to give him hope. B) Do not overwhelm the client with such a big decision. C) There is a reduced ability for your husband to be able to father children. D) We will provide you and the client with a counselor so that you can explore all options
C It is essential that the wife understand that there may be difficulty in the client fathering a baby. With such a devastating injury, it would be very difficult to raise the client's hope and then be told that that possibility is taken away. The nurse would not encourage the wife to tell the client something which may not be able to happen. The nurse would not allow the client's wife to be misinformed by alluding to the fact that it is a big decision. It is appropriate to consult a counselor to explore all options, but first the wife and client must understand the facts
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? A) Provide instruction on blood-thinning medication. B) Praise client when using adaptive equipment. C) Include client in planning of care and setting of goals. D) Assess client for ability to ambulate independently
C The client in a rehabilitation setting has moved to the recovery phase. The highest priority is to include the client in the rehabilitation plan. Tailoring the rehabilitation plan to meet the needs of the client can promote optimal participation by the client in the rehabilitative process. The other options are appropriate in certain situations but not the highest priority
The nurse caring for a client in the chronic phase of a neurologic deficit knows that nursing management focus 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
D 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 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? A) Ineffective Coping related to refusing to acknowledge physical limitations B) Deficient Diversional Activity related to the inability to participate in family activity C) Impaired Home Maintenance related to inability to care for home setting D) Ineffective Role Performance related to inability to function in family role
D 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
What phase of a neurologic deficit begins when the client's condition is stabilized? A) Recovery B) Chronic C) Terminal D) Acute
A The recovery phase begins when the client's condition is stabilized. It starts several days or weeks after the initial event and lasts weeks or months. This makes options B, C, and D incorrect.
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. A) Impaired speech B) Abnormal bladder elimination C) Muscle strength D) Normal gait E) Paralysis
A, B, E A neurologic deficit a condition in which one or more functions of the central and peripheral nervous systems are decreased, impaired, or absent. Examples include paralysis, muscle weakness, impaired speech, inability to recognize objects, abnormal gait or difficulty walking, impaired memory, impaired swallowing, or abnormal bowel and bladder elimination
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? A) Provide a well-lit environment. B) Announce yourself when approaching the client. C) Ensure a clutter-free walkway. D) Instruct on adaptive plates with rims
C The most helpful nursing intervention for the Impaired Physical Mobility nursing diagnosis is to ensure a clutter-free walkway. With the absence of the visual field, a clutter-free walkway is a safety issue. All of the other interventions are also appropriate.
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? A) Urinary incontinence B) Urinary retention C) Decreased energy expenditure D) Relaxation of the internal bladder sphincter
D An age-related delay in the relaxation of the internal bladder sphincter may make bladder training difficult. Urinary incontinence, urinary retention, and decreased energy expenditure are not the factors that make bladder training difficult for older adult clients with neurologic deficit.
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 yourself and return later. B) Inquire what the client is thinking about. C) Ask the client if he would like a few minutes alone. D) Perform duties professionally and explain that spontaneous erections are unpredictable
D 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 yourself, 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.
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? A) Occupational therapy B) Range-of-motion (ROM) exercises C) Recreational therapy D) Physiotherapy
A Occupational therapy is designed to help strengthen muscles that are under voluntary control. ROM exercises maintain joint flexibility and prevent permanent contractures. Participation in recreational therapies increases socialization time.
When using pharmacologic aids to assist with bowel training, which aid would the nurse anticipate to be used first? A) A mineral oil enema B) A glycerin suppository C) A bisacodyl suppository D) Prune juice
B When using a pharmacologic aid, the nurse would anticipate using the mildest form first beginning with a glycerin suppository. Glycerin suppositories provide gentle, timely, and effective relief. The glycerin suppository lubricates, irritates, and softens the fecal matter. A mineral oil enema is instilled higher in the bowel and coats the stool and stimulates the bowel. Prune juice is a fruit juice and not a pharmacological aid
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? A) Obtaining a laxative B) Eating a select diet C) Recording bowel movements D) Providing privacy
C 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.
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? A) Lightly massage or tap the skin above the pubic area. B) Press directly over the urinary bladder. C) Bear down increasing abdominal pressure. D) Pour water over the genitals.
A Cutaneous triggering performed by massaging or tapping lightly over the pubic area stimulates relaxation of the urinary sphincter. Pressing over the urinary bladder is a component of the Credé's maneuver, which does not relax the urinary sphincter. Bearing down with mouth and nose shut is a component to the Valsalva maneuver. Pouring water over the genitals is ineffective in a paralyzed client.
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? A) "The client may be experiencing a change in affect due to the brain injury." B) "The client has demonstrated this behavior before and is now anticipated." C) "The client has underlying aggression problems, which manifest in behavior." D) "All traumatic brain injury clients act in this similar way."
A It is not unusual for the family to identify a change in affect following a traumatic brain injury. This may include an alteration of lability of mood. Explaining this change to family is important in helping them understand the client's actions. Stating that the client has done this before and this is now anticipated does not provide the understanding and the support for the mother. There is no information provided to confirm past aggression problems. Not all traumatic brain injuries have a change in mood.
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? A) The client grasps the affected arm at the wrist and raises it. B) The client arranges a community service to deliver meals. C) The client ambulates with the assistance of one. D) The client uses a mechanical lift to climb steps.
A The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance
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? A) Steps to the front door B) Tub for bathing C) Throw rugs in the kitchen D) Untrained companion staying with client
A 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.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? A) The client will take the seizure medication at the same time daily. B) The client will remain free of injury if a seizure does occur. C) The client will verbalize an understanding of feelings that preempt seizure activity. D) The client will post emergency numbers on the refrigerator for ease of obtaining.
B All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
The nurse is caring for clients on a neurologic floor. Which client goal is most 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
B 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.
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? A) Cardiovascular system B) Respiratory system C) Endocrine system D) Neurovascular system
D The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.
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? A) Goal is to keep the client stable and prevent or treat complications, such as pneumonia, and further neurologic impairment. B) Goal is to plan a rehabilitation program in several domains according to the client's abilities and limitations. C) Goal is to admit the client to a hospital for treatment of complications. D) Goal is to stabilize the client and prevent further neurologic damage
D The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage. The client with a CVA may require management of hypertension or hypotension through drug therapy. The client with a head or spinal cord injury may require respiratory support through mechanical ventilation or surgical intervention to stabilize the injured area or remove bone fragments, blood clots, or foreign objects. Sometimes, surgery is postponed until the client is stabilized and the acute phase has passed. In other instances, surgery is performed during the acute phase as a lifesaving measure. Option A is the aim of medical management of the recovery phase; Options B and C are nursing goals, not medical goals for different phases of neurologic deficit.
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? A) Birth control pills B) A rescue inhaler C) An analgesic D) An antihistamine
A The nurse realizes that the female, paralyzed client has the ability to ovulate and become pregnant. Birth control pills are needed until a decision regarding an additional pregnancy is achieved. The other options are also important to consider but does not have the significant consequences
Which of the following occupations are anticipated to improve the functioning of a client with a neurologic deficit? Select all that apply. A) Occupational therapist B) Speech therapist C) Neurologist D) Electrocardiography technician E) Electroencephalogram technician F) Physical therapist
A, B, C, F The following occupations work with the client with neurologic deficits and improve his 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 neurologist prescribes medical care and coordinates the treatment team. 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. Both do not improve functioning.
Which of the following would the nurse include in the rationale for the nursing intervention to maintain body alignment? Select all that apply. A) Maintaining body alignment prevents contractures B) Maintaining body alignment promotes circulation C) Maintaining body alignment assists in urinary elimination D) Maintaining body alignment decreases pain E) Maintaining body alignment decreases respiratory effort
A, D Maintaining body alignment prevents contractures and decreases pain from misalignment of the musculoskeletal system. In some cases, maintaining alignment may promote circulation, assist in urinary elimination, and decrease respiratory effort but not routinely to include in the general rationale.
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 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
B 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 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? A) "There is nothing you can do. It must come from the client." B) "Grief is a normal process. Let's discuss offering support throughout the process." C) "Ask your loved one what you can do and decorate the room to elevate mood." D) "Provide comfort foods, which expresses your love and support."
B The best response by the nurse is to confirm that what the client is experiencing is a normal process and opening conversation. The nurse is also helpful to identify the upcoming process that the client will be experiencing. Stating that there is nothing that the family member can do closes communication and is inaccurate. The other responses may be helpful but are not the best.
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? A) Use of parallel bars or a walker B) Application of an abdominal binder C) Use of a footboard D) Use of a flotation mattress
C A footboard positions the foot and ankle in such a way as to prevent plantar flexion. Parallel bars help the client with impaired mobility to support body weight and move forward before ambulating independently. An abdominal binder prevents dizziness and faintness. A flotation mattress helps relieve pressure when the client is lying down and sitting.
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? A) Transient ischemic attack (TIA) B) Malignant brain tumor C) Parkinson's disease D) Pneumonia
C The clients with Parkinson's disease are often admitted to the hospital for treatment of complications. Sometimes, when their disease process progresses, they are also admitted to a skilled nursing facility. A transient ischemic attack causes transient symptoms or minor neurologic deficits. A malignant brain tumor typically causes debilitating symptoms and spreads due to the malignant nature causing death. Pneumonia is a complication of neurologic deficits, but itself is not a neurologic deficit. Pneumonia can be resolved with antibiotics depending on the status of the client.
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) "I am so happy to be home, but I am not able to go upstairs to my bedroom." B) "I find it difficult to get up so I am remaining in bed until the home health aide comes." C) "My spouse goes to work in the morning and leaves my lunch at my bed stand." D) "A lot of family is coming to see me, which is nice but makes me very tired."
C 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
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? A) Use the Glasgow Coma Scale. B) Use the Mini-Mental Status Examination. C) Report the change to the physician. D) Monitor the blood pressure.
C When significant changes occur, the nurse should immediately report them to the physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools, such as the Mini-Mental Status Examination, to perform the neurologic assessments to evaluate the client's status. The nurse maintains the blood pressure to ensure adequate cerebral oxygenation.
