ATI LPN
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 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?
Correct Answer: A
Rationale: Though it is first addressed in the acute phase, the prevention of joint contractures is most helpful in promoting the rehabilitation of this client. The nursing care provided at an early period can prevent further complications in the rehabilitative phase. Promoting the ability to think critically 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.
Question 2 of 5
A nurse is assisting a client with a neurologic deficit with bowel training. Which pharmacologic aid would the nurse anticipate to be used first?
Correct Answer: A
Rationale: When using a pharmacologic aid, the nurse would anticipate using the mildest form first beginning with a stool softener. Stool softeners moisturize the feces, which facilitates passage of stool without straining. The other Classifications could also be appropriate but not used first.
Question 3 of 5
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?
Correct Answer: D
Rationale: 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 oneself, 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.
Question 4 of 5
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?
Correct Answer: A
Rationale: Motor paralysis does not affect ovulation. It is important for the nurse to review the need for continued contraceptive use with the client if a pregnancy is still undesired. A nonsteroidal anti-inflammatory, an analgesic, and an antihistamine used prior to the spinal cord injury may be reviewed prior to discharge but are lower priority.
Question 5 of 5
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?
Correct Answer: A
Rationale: 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.