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 with neurologic deficits who is interested in implementing a bowel training program. Which does the nurse identify as the first step?
Correct Answer: C
Rationale: 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.
Question 2 of 5
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?
Correct Answer: B
Rationale: 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.
Question 3 of 5
The nurse is instructing the client on how to perform Cred?© maneuver. In which situation is this maneuver helpful?
Correct Answer: C
Rationale: Cred?©'s maneuver is intended to increase abdominal pressure and facilitate 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.
Question 4 of 5
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?
Correct Answer: A
Rationale: 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 Cred?© 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.
Question 5 of 5
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?
Correct Answer: B
Rationale: 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.