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 an 82-year-old client who needs bladder training. The nurse knows that bladder training is difficult for older adult clients with neurologic deficit because of what?
Correct Answer: D
Rationale: 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.
Question 2 of 5
A nurse is caring for a client who has a neurologic deficit. What would the nurse do to assist this client in increasing peristalsis and encouraging defecation?
Correct Answer: A
Rationale: 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.
Question 3 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 4 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 5 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.