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
A nurse is caring for a client diagnosed with neurologic deficit who has recently become responsive when interacted with. What therapy should the nurse suggest to help strengthen muscles that are under voluntary control?
Correct Answer: A
Rationale: Occupational therapy is designed to help strengthen muscles that are under voluntary control. ROM exercises maintain joint flexibility and prevent permanent contractures. Participation in recreational and music therapies increases socialization time.
Question 3 of 5
A nursing instructor is teaching the senior nursing class about clients with neurologic disorders. The instructor tells the students that these clients are at risk of disuse syndrome due to musculoskeletal inactivity and neuromuscular impairment. What nursing intervention helps prevent plantar flexion?
Correct Answer: C
Rationale: A footboard positions the foot and ankle in such a way as to prevent plantar flexion. Parallel bars help the client with impaired mobility to support body weight and move forward before ambulating independently. An abdominal binder prevents dizziness and faintness. A flotation mattress helps relieve pressure when the client is lying down and sitting.
Question 4 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 5 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.