Chapter 40: Caring for Clients With Neurologic Deficits - Nurselytic

Questions 26

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ATI LPN TextBook-Based Test Bank

Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition

Chapter 40 : Caring for Clients With Neurologic Deficits Questions

Question 1 of 5

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?

Correct Answer: B

Rationale: The nurse uses assessment tools such as the Mini-Mental Status Examination to perform the neurologic assessment. Cutaneous triggering and Cred?©'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.

Question 2 of 5

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

Correct Answer: A

Rationale: 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 the other options incorrect.

Question 3 of 5

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?

Correct Answer: D

Rationale: 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. Keeping the client stable and preventing or treating complications is the aim of medical management of the recovery phase. Planning a rehabilitation program according to the client abilities and limitations and admit the client for treatment of complications are nursing goals, not medical goals for different phases of neurologic deficit.

Question 4 of 5

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?

Correct Answer: D

Rationale: 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.

Question 5 of 5

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

Correct Answer: B

Rationale: 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.

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