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 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 2 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 3 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.
Question 4 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 5 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.