Delegation and Prioritization Practice (Neuro) – Flashcards

Answer: A Rationale: The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is urgent like the issue of pain, which is often incapacitating.

Answer: A, B, C, D, E Rationale: Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are more accurate.

Answer: C Rationale: Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary.

Answer: B Rationale: The LPN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.

Answer: D Rationale: A client with a seizure disorder should not take OTC medications without consulting with a health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.

Answer: C Rationale: The UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client with ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.

Answer: A Rationale: Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from re-injury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times.

Answer: B Rationale: The signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. adjusting the room temperature may be helpful, because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the physician may be necessary if nursing actions do not resolve symptoms.

Answer: B Rationale: The new RN graduate who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson's disease to bathe is best delegated to the UAP. The client being transferred to the nursing home and the newly-admitted client with SCI should be assigned to experienced nurses.

Answer: D Rationale: The first priority for the client with an SCI is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise, because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority.

Answer: B Rationale: The UAPs training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses.

Answer: A, B, D, E Rationale: All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding.

Answer: A, C, D Rationale: Checking and observing for signs of pressure or infection is within the scope of practice of the LPN. The LPN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional nurse.

Answer: C Rationale: The client's statement indicates impaired individual resilience in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate for a client with SCI but are not related to the client's statement.

Answer: B Rationale: The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the ICU. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care.

Answer: D Rationale: At this time, based on the client's statement, the priority is Bathing Self-Care Deficit related to fatigue after physical therapy. The other three nursing diagnoses are appropriate to a patient with MS but are not related to the client's statement.

Answer: D Rationale: The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure. which requires urgent intervention. The other findings are important and should be reported to the nurse. but they are not life threatening.

Answer: B Rationale: The changes that the UAP is reporting are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation.

Answer: C Rationale: Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug such as alteplase can worsen the bleeding. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.

Answer: A Rationale: Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.

Answer: A, B, C, E Rationale: An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. Assessing for redness and swelling (signs of DVT) requires additional education and skill, appropriate to the professional nurse.

Answer: A Rationale: Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.

Answer: B Rationale: Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce CNS stimulation and irritation and should be implemented as soon as possible, but are not as important as starting antibiotic therapy.

Answer: A Rationale: Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions ma not be appropriate but do not require intervention as rapidly. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.

Answer: A, B Rationale: Any nursing staff member who is involved in caring for the client should observe for the onset and duration of any seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN education and scope of practice. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.

Answer: A Rationale: The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side. Administering lorazepam should be the next action, because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase. the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness.

Answer: B Rationale: Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment and/or client teaching but will not require a change in a medical treatment for the seizures.

Answer: D Rationale: UTIs are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The physician should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.

Answer: A, C, E Rationale: UAP education and scope of practice include taking pulse and blood pressure measurements. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.

Answer: A Rationale: LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility.

Answer: B Rationale: The husband's statement about lack of sleep and anxiety about whether his wife is receiving the correct medications are behaviors that support this diagnosis. There is not evidence that the client's cardiac output is decreased. The husband's statements about how he monitors the client and his concern with medication administration indicate that the risk for ineffective family therapeutic regimen management and falls are not priority diagnoses at this time.

Answer: A Rationale: The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in ICP. This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies.

Answer: B Rationale: The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.

Answer: C Rationale: Of the clients listed, the client with bacterial meningitis is in the most stable condition. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experience in caring for clients with neurologic diagnoses.