ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 40 Questions
Question 1 of 5
A client with a neurologic deficit has been admitted to the nursing unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
Correct Answer: C
Rationale: When significant changes occur, the nurse should immediately report them to the physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools, such as the Mini-Mental Status Examination, to perform the neurologic assessments to evaluate the client's status. The nurse maintains the blood pressure to ensure adequate cerebral oxygenation.
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 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 4 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 5 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.