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
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 2 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.
Question 3 of 5
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?
Correct Answer: C
Rationale: 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.
Question 4 of 5
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?
Correct Answer: C
Rationale: Clients with Alzheimer 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.
Question 5 of 5
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?
Correct Answer: D
Rationale: 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.