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 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 2 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 3 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.
Question 4 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 5 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.