Question 1

You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficit because of what?
A) Urinary incontinence
B) Urinary retention
C) Decreased energy expenditure
D) Relaxation of the internal bladder sphincter

Accepted Answer

Relaxation of the internal bladder sphincter is a common problem in older adult clients with neurologic deficit. This can lead to urinary incontinence, which can make bladder training difficult.

Question 2

You have admitted a new client to the neuro ICU. You have performed a general neurologic assessment and are preparing to use a standardized assessment tool to assess the extent of neurologic deficits related to which of the following?
A) Knowledge
B) Math
C) Thought processes
D) Speech

Accepted Answer

The extent of neurologic deficits related to speech can be assessed using a standardized assessment tool such as the National Institutes of Health Stroke Scale (NIHSS). This tool assesses speech clarity, word finding difficulties, and responsiveness to verbal commands. Assessing deficits in knowledge, math, and thought processes would require different assessment tools specific to those areas.

Question 3

A student nurse is working with a preceptor on a rehabilitation unit. One of their clients has a neurologic deficit. What nursing intervention may help the client maintain independence as long as possible?
A) Provide encouragement and praise.
B) Encourage the client to set attainable goals.
C) Suggest available support groups.
D) Show personal interest and pleasure in each accomplishment.

Accepted Answer

Encouraging the client to set attainable goals can help them maintain independence as long as possible. This allows the client to feel a sense of control and accomplishment, which can boost their self-esteem and motivation. It also helps the client to focus on what they can do, rather than what they can't do due to their neurologic deficit. Option A, C, and D are also important interventions, but they do not directly address maintaining independence.

Question 4

A paraplegic client is distressed and wants to know about fathering a child. What should the nurse tell the client?
A) The buoyancy of a water bed promotes potential for fertility.
B) Penile implants provide potential for fertility.
C) Motor paralysis does not affect potential for fertility.
D) Ejaculation is rare.

Accepted Answer

The answer of A paraplegic client is distressed and wants...

Question 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?
A) Goal is to keep the client stable and prevent or treat complications, such as pneumonia, and further neurologic impairment.
B) Goal is to plan a rehabilitation program in several domains according to the client's abilities and limitations.
C) Goal is to admit the client to a hospital for treatment of complications.
D) Goal is to stabilize the client and prevent further neurologic damage.

Accepted Answer

The nurse should know that the goal of medical management in the acute phase of neurologic deficit in a client with fractured vertebrae is to stabilize the client and prevent further neurologic damage. Other goals, such as planning a rehabilitation program or treating complications, may come later in the client's treatment but are not the priority in the acute phase.

Question 6

A client is brought to the Emergency Department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply.
A) Impaired speech
B) Abnormal bladder elimination
C) Muscle strength
D) Normal gait
E) Paralysis

Accepted Answer

Neurologic deficits refer to impairments in the functioning of the nervous system. Impaired speech (A) can result from damage to the parts of the brain responsible for language. Abnormal bladder elimination (B) can be caused by nerve damage affecting bladder control. Paralysis (E) is a loss of muscle function in part of your body, which can occur due to damage to the nerves that control those muscles. Muscle strength (C) and normal gait (D) are not considered deficits but rather normal functions or potential outcomes of successful treatment or rehabilitation.

Question 7

A student nurse is giving a report on clients with bladder problems. What instructions related to bladder care should the student nurse include in her report on clients with bladder problems?
A) The client should start a bladder training program when all else fails to work.
B) The client should use continence pads.
C) The client should take in adequate fluids.
D) The client should eat a high-fiber diet.

Accepted Answer

Adequate fluid intake is essential for bladder health as it helps to flush out bacteria and prevent infections.

Question 8

A client has a neurologic deficit that was just diagnosed. In what phase of the neurologic deficit is this client?
A) Onset
B) Chronic
C) Recovery
D) Acute

Accepted Answer

The onset phase is the initial manifestation of symptoms. The acute phase is characterized by the sudden onset of neurological deficits. The chronic phase follows the acute phase and may have long-term deficits. The recovery phase is the stage in which some function returns after a period of deficit. Therefore, since the client was just diagnosed, they are likely in the acute phase.

Question 9

A client with a neurologic deficit has been admitted to your 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?
A) Use the Glasgow Coma Scale.
B) Use the Mini-Mental Status Examination.
C) Report the change to the physician.
D) Monitor the blood pressure.

Accepted Answer

Any significant changes in a client's condition should be reported immediately to the physician in order to provide prompt intervention and prevent further complications. The Glasgow Coma Scale and Mini-Mental Status Examination may be used to assess the client's level of consciousness and cognitive function, but they do not address the immediate need for intervention when there are significant changes in a client's status. Monitoring the blood pressure is also important, but it should not take priority over reporting significant changes to the physician.

Question 10

A nursing instructor is teaching the senior nursing class about clients with neurologic disorder. 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?
A) Use of parallel bars or a walker.
B) Application of an abdominal binder.
C) Use of a footboard.
D) Use of a flotation mattress.

Accepted Answer

The use of a footboard helps prevent plantar flexion by keeping the feet properly aligned and preventing them from dropping. Parallel bars or a walker help with overall mobility, but they do not specifically address plantar flexion. An abdominal binder helps with abdominal support but does not prevent plantar flexion. A flotation mattress is typically used for pressure ulcer prevention and does not address musculoskeletal or neuromuscular issues.

Question 11

A nurse has just implemented a bladder training program with a client who has a neurologic deficit. The nurse instructs the client to bend at the waist or press inward and downward over the bladder. What statement justifies this action?
A) It stimulates the relaxation of the urinary sphincter.
B) It increases abdominal pressure.
C) It helps the client to identify voiding.
D) It reduces the calculus formation in the urinary tract.

Accepted Answer

Bending at the waist or pressing inward and downward over the bladder increases abdominal pressure, which can help stimulate bladder contraction and facilitate voiding in clients with urinary retention related to neurologic deficits.

Question 12

A client is in the recovery phase of neurologic deficit. What does medical management in this phase aim at?
A) Stabilizes the client and prevents further neurologic damage
B) Curing the client
C) Keeping the client stable and preventing or treating complications
D) Uses a wide range of therapies and treatments

Accepted Answer

In the recovery phase of neurologic deficit, medical management aims at keeping the client stable and preventing or treating complications. This includes preventing further damage, managing symptoms, and providing rehabilitative care. While a range of therapies and treatments may be used, the primary focus is on stabilizing and supporting the client through the recovery process, rather than curing them.

Question 13

What phase of a neurologic deficit begins when the client's condition is stabilized?
A) Recovery
B) Chronic
C) Terminal
D) Acute

Accepted Answer

The recovery phase of a neurologic deficit begins when the client's condition is stabilized. This is the phase where the client starts to regain function and may begin rehabilitation to further improve their abilities. The chronic phase refers to a long-term condition where the deficits persist but are not worsening. The terminal phase refers to end-of-life care when the deficits can no longer be managed. The acute phase refers to the initial onset of the deficit and the period of time immediately following it.

Question 14

When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapies should the nurse suggest to help strengthen muscles that are under voluntary control?
A) Occupational therapy
B) Range-of-motion (ROM) exercises
C) Recreational therapy
D) Physiotherapy

Accepted Answer

The answer of When a nurse is caring for a...

Question 15

Some clients go into the chronic phase of neurologic deficit. What does the client do in this phase?
A) The client improves slowly over time.
B) The client shows little or no improvement, remains stationary, or progressively worsens.
C) The client does some rehabilitation work but progresses slowly.
D) The client is in a state of flux having exacerbations and getting better.

Accepted Answer

In the chronic phase of neurologic deficit, the client shows little or no improvement, remains stationary, or progressively worsens. This phase can last for months to years and may require ongoing supportive care.

Question 16

During the recovery phase of neurologic deficit, what healthcare professionals are part of the team approach to planning and overseeing the care of these clients? Select all that apply.
A) Prosthetist
B) Pharmacy tech
C) Physical therapy aide
D) Dietitian
E) Nursing assistant

Accepted Answer

The answer of During the recovery phase of neurologic deficit,...

Question 17

The nurse is writing a plan of care for a client who is in spinal shock. What is one nursing diagnosis the nurse would be sure to include?
A) Enhanced physical mobility
B) Potential sexual function
C) Risk for Disuse Syndrome
D) Risk for urinary continence

Accepted Answer

Risk for Disuse Syndrome is a relevant nursing diagnosis for a client in spinal shock because it addresses the potential complications related to immobility, such as muscle atrophy and joint stiffness, which are common in patients with spinal injuries.

Question 18

A nurse is assisting a client with a neurologic deficit to have a bowel movement. Which of the following nursing actions increases peristalsis and encourages defecation?
A) Help the client to the bathroom at a particular time each day.
B) Administer a low-volume enema each day at the same time.
C) Encourage liquids throughout the day.
D) Encourage a high-fiber diet.

Accepted Answer

The answer of A nurse is assisting a client with...

Question 19

Which of the following assessment tools should the nurse use to perform a neurologic assessment?
A) Cutaneous triggering
B) Mini-Mental Status Examination
C) Credé's maneuver
D) Mechanical lift

Accepted Answer

The Mini-Mental Status Examination is a tool used to assess cognitive function and is often used as part of a neurologic assessment. Cutaneous triggering, Credé's maneuver, and a mechanical lift are not assessment tools used for neurologic assessments.

Question 20

A client is being discharged home with a neurologic deficit. The nurse has finished discharge teaching. What should the nurse have taught the client and their family about the medications prescribed for the client and members of the healthcare team?
A) Open capsules and put in ice cream to facilitate swallowing.
B) Advise family members to check with their physician or pharmacist before crushing or breaking tablets or opening capsules.
C) Crush pills that are difficult for the client to swallow.
D) All the medicine will be provided in liquid form.

Accepted Answer

It is important for family members to check with their physician or pharmacist before crushing or breaking tablets or opening capsules, as some medications are not meant to be altered in this way and doing so can affect their effectiveness or cause harm to the client.

Quiz 40: Caring for Clients With Neurologic Deficits

You are caring for an 82-year-old client who needs bladder training. You know that bladder training is difficult for older adult clients with neurologic deficit because of what?

You have admitted a new client to the neuro ICU. You have performed a general neurologic assessment and are preparing to use a standardized assessment tool to assess the extent of neurologic deficits related to which of the following?

A student nurse is working with a preceptor on a rehabilitation unit. One of their clients has a neurologic deficit. What nursing intervention may help the client maintain independence as long as possible?

A paraplegic client is distressed and wants to know about fathering a child. What should the nurse tell the client?

A client is brought to the Emergency Department (ED) by family members who tell the triage nurse that the client doesn't recognize them. The client is diagnosed with a neurologic deficit. What other conditions are considered neurologic deficits? Select all that apply.

A student nurse is giving a report on clients with bladder problems. What instructions related to bladder care should the student nurse include in her report on clients with bladder problems?

A client has a neurologic deficit that was just diagnosed. In what phase of the neurologic deficit is this client?

A client with a neurologic deficit has been admitted to your 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?

A nurse has just implemented a bladder training program with a client who has a neurologic deficit. The nurse instructs the client to bend at the waist or press inward and downward over the bladder. What statement justifies this action?

A client is in the recovery phase of neurologic deficit. What does medical management in this phase aim at?

What phase of a neurologic deficit begins when the client's condition is stabilized?

When a nurse is caring for a client diagnosed with neurologic deficit who has begun responding to those around him, what therapies should the nurse suggest to help strengthen muscles that are under voluntary control?

Some clients go into the chronic phase of neurologic deficit. What does the client do in this phase?

During the recovery phase of neurologic deficit, what healthcare professionals are part of the team approach to planning and overseeing the care of these clients? Select all that apply.

The nurse is writing a plan of care for a client who is in spinal shock. What is one nursing diagnosis the nurse would be sure to include?

A nurse is assisting a client with a neurologic deficit to have a bowel movement. Which of the following nursing actions increases peristalsis and encourages defecation?

Which of the following assessment tools should the nurse use to perform a neurologic assessment?

A client is being discharged home with a neurologic deficit. The nurse has finished discharge teaching. What should the nurse have taught the client and their family about the medications prescribed for the client and members of the healthcare team?