Ch 15 study
The nurse receives a report from a licensed practical nurse about care provided to clients on a neurologic unit. It is most important for the nurse to follow up on which statement first? Multiple choice question "The 84-year-old client with Alzheimer disease is depressed and anxious." "The 45-year-old client with Huntington disease has writhing movements of both hands." "The 72-year-old client with Parkinson disease reports dizziness when standing up." "The 15-year-old client with Tourette syndrome is repeating words over and over again."
"The 72-year-old client with Parkinson disease reports dizziness when standing up." The client with Parkinson disease has orthostatic hypotension (dizziness when standing) and is at risk for falls. The clinical manifestations exhibited by the other clients are expected; these clinical manifestations are not priority client safety concerns. p. 381
Which clients have basal ganglia motor syndromes? Multiple selection question A client diagnosed with poliomyelitis A client diagnosed with Parkinson disease A client diagnosed with a spinal cord injury A client diagnosed with Tourette syndrome A client diagnosed with Huntington disease
A client diagnosed with Parkinson disease A client diagnosed with Huntington disease Symptoms of Parkinson disease and Huntington disease are caused by disorders of the basal ganglia. Poliomyelitis is a lower motor neuron syndrome. Spinal cord injury, depending upon the break, can affect upper or lower motor neurons. Tourette syndrome could be a cortico-striato-thalamocortical dysfunction and, in some cases, altered dopaminergic neurotransmission, but the pathophysiology is unclear. p. 386
The nurse is caring for a client diagnosed with increased intracranial pressure. Which assessment finding should indicate to the nurse that the client's brain has experienced an uncal herniation? Multiple choice question Pinpoint pupils Cheyne-Stokes breathing Supraventricular tachycardia Increased restlessness and agitation
Cheyne-Stokes breathing Clinical manifestations of an uncal brain herniation include abnormal breathing patterns, such as Cheyne-Stokes breathing. Other clinical manifestations include dilated and fixed pupils and a decreasing level of consciousness and posturing. Supraventricular tachycardia and increased restlessness and agitation are not associated with this type of herniation. p. 375
A client has basal ganglion damage. Which muscle tone alteration will the nurse observe upon assessment? Multiple choice question Dystonia Flaccidity Cogwheel Alpha rigidity
Cogwheel Cogwheel is a type of hypertonia caused by basal ganglion damage. Alpha rigidity is caused by a loss of cerebellum input to the lateral vestibular nuclei; dystonia is produced by slow muscle contractions or lack of reciprocal inhibition of muscle. Flaccidity occurs when nerve impulses for muscle tone are lost. p. 377
A nurse observes the client in the position illustrated in the diagram (see image). How should the nurse chart this finding? Multiple choice question Deep coma Moderate coma Decorticate posturing Decerebrate posturing
Decerebrate posturing Decerebrate posturing is demonstrated by abnormal extension. The arms are extended, with hyperpronation of the forearms and plantar extension of the feet. Coma is not characterized by physical characteristics but rather by deviations in consciousness. Decorticate posturing is characterized by abnormal flexion of the arms, wrists, and fingers with adduction in upper extremities. The lower extremities experience extension, internal rotation, and plantar flexion. p. 364
A nurse is caring for a client with Parkinson disease. Which pathophysiologic process must the nurse consider when planning care for this client? Multiple choice question Abnormal, involuntary movements that occur as spasms Autosomal dominant trait with mutation on chromosome 4 Lower motor neuron syndrome originating in the anterior horn Degeneration of the basal ganglia with loss of dopamine-producing neurons
Degeneration of the basal ganglia with loss of dopamine-producing neurons There is degeneration of the basal ganglia with dysfunctional or misfolded α-synuclein protein and loss of dopamine-producing neurons in the substantia nigra and dorsal striatum in Parkinson disease. Amyotrophic refers to the predominant lower motor neuron components. Paroxysmal dyskinesias are abnormal, involuntary movements that occur as spasms. Huntington disease is inherited as an autosomal dominant trait with high penetrance. The gene whose mutation leads to Huntington disease is located on the short arm of chromosome 4. p. 380
A client has hypokinesia. The nurse will observe which finding upon assessment? Multiple choice question Lip smacking Expressionless face Varied speech inflections Numerous spontaneous gestures
Expressionless face Decreased associated movements accompanying emotional expression cause an expressionless face, a statue-like posture, absence of speech inflection, and absence of spontaneous gestures for an individual with hypokinesia. Lip smacking occurs in tardive dyskinesia. p. 380
A client is diagnosed with spinal shock. Which assessment findings should the nurse expect to observe? Multiple choice question Muscle spasms and clonus Hyperactive reflexes and hypertonia Flaccid paralysis and absent reflexes Extreme weakness of the lower extremities
Flaccid paralysis and absent reflexes Characteristics of spinal shock include flaccid paralysis and absence of reflexes. Muscle spasms, clonus, hyperactive reflexes, and hypertonia occur after spinal shock resolves. A client in spinal shock develops paralysis, not weakness of the lower extremities. pp. 366-367
A client is diagnosed with Parkinson disease. Which clinical manifestation will the nurse expect to observe? Multiple choice question Paralysis Hydrocephalus Flexed, forward leaning posture Increased intracranial pressure
Flexed, forward leaning posture Postural abnormalities (flexed, forward leaning), difficulty walking, and weakness develop in Parkinson disease. There is no true paralysis in Parkinson disease. Hydrocephalus and increased intracranial pressure do not occur in Parkinson disease. p. 381
Which mechanism causes uncontrolled, excessive movements in a client with Huntington disease? Multiple choice question Excessive production of dopamine Gamma-aminobutyric acid depletion Inadequate availability of catecholamines Altered function at the myoneural junctio
Gamma-aminobutyric acid depletion Depletion of gamma-aminobutyric acid, an inhibitory neurotransmitter, is the principal mechanism that causes motor and mental function alterations in Huntington disease. Dopamine and catecholamine production are not altered in Huntington disease. Huntington disease causes severe degeneration of the basal ganglia, not the myoneural junction. p. 380
Which reflexes, if exhibited by the client, would indicate loss of cortical inhibition? Multiple selection question Grasp Corneal Sucking Swallow Palmomental
Grasp Sucking Palmomental Reflexes associated with loss of cortical inhibition include the grasp reflex, reflex sucking, and palmomental reflex. Gag and swallow reflexes are normal reflexes; these reflexes test function of cranial nerves IX and X. Corneal reflex is a normal reflex and tests function of cranial nerves V and VII. p. 363
A client presents with a wild, flinging movement of the left arm and left leg. Which term will the nurse use to document this clinical manifestation? Multiple choice question Akinesia Akathisia Hemiballism Hemiparesis
Hemiballism Hemiballism is a disorder of the proximal muscle postural fixation with wild flinging movements of the limbs on one side of the body. Akinesia is a decrease in voluntary and associated movements. Akathisia is a mild compulsion to move. Hemiparesis is weakness on one side of the body. p. 379
A client is diagnosed with Huntington disease. Which information will the nurse teach the client? Multiple selection question It is a type of chorea. It is a nonhereditary disease. It is asymptomatic until the sixth decade of life. It is a commonly diagnosed neurologic disorder. It is a severe degeneration of an area in the brain.
It is a type of chorea. It is a severe degeneration of an area in the brain. Huntington disease is a type of chorea. The principal pathologic feature is severe degeneration of the basal ganglia, particularly the caudate nucleus, located in the brain. It is a relatively rare hereditary, degenerative disorder. It most commonly affects those between the ages of 25 and 45. pp. 379-380
A client has delirium. When planning care, what should the nurse remember about the typical duration of this condition? Multiple choice question It is irreversible. It lasts hours to weeks. It lasts months to years. It lasts seconds to minutes.
It lasts hours to weeks. Delirium has a duration of hours to weeks. Seconds to minutes is too short. Dementia is months to years and is irreversible. p. 370
Which term will the nurse use to describe a client who sustains a cerebrovascular accident with paralysis on the left side? Multiple choice question Left paraplegia Left hemiplegia Right hemiplegia Right paraplegia
Left hemiplegia Hemiplegia means loss of motor function on the upper and lower extremities on one side of the body. Because the paralysis is on the left side, it is called left hemiplegia. If the paralysis were on the right side of the body, it would be called right hemiplegia. Paraplegia refers to loss of motor function of the lower extremities, so it is neither right nor left, because both legs are paralyzed. p. 382
A client who experienced a head injury to the frontal lobe develops gegenhalten (paratonia). Which clinical manifestation will the nurse expect to observe? Multiple choice question Limp, atrophied muscles Resistance to passive movements Decerebrate rigidity of lower extremeties Writhing, twisted movements of both arms
Resistance to passive movements Resistance to passive movements is characteristic of gegenhalten (paratonia), a type of hypertonia. Limp, atrophied muscles occur with hypotonia and flaccidity. Decerebrate rigidity is termed gamma. Writhing, twisted movements is termed chorea. p. 377
Which client is most at risk for the sudden development of secondary parkinsonism? Multiple choice question The client that initiated the use of salt substitutes. The client that was prescribed a neuroleptic medication. The client that started taking an herbal supplement to treat depression. The client that abruptly stopped taking a medication used to treat epilepsy.
The client that was prescribed a neuroleptic medication. Drug-induced parkinsonism, caused by neuroleptics, antiemetics, and antihypertensives, is the most common secondary form of parkinsonism and usually is reversible. Secondary parkinsonism is not caused by herbal supplementation, abrupt discontinuation of antiseizure medications, or use of salt substitutes. p. 380
A client is diagnosed with Parkinson disease. The daughter asks the nurse to explain what causes this disorder. Which information is the best? Multiple choice question There is a lack of dopamine, which leads to rigidity. There is too much dopamine, which leads to limpness. There is a lack of acetylcholine, which leads to rigidity. There is too much acetylcholine, which leads to limpness.
There is a lack of dopamine, which leads to rigidity. Parkinson disease involves degeneration of dopaminergic neurons, creating a dopamine deficiency in the basal ganglia. Dopamine is important for opposing the action of the neurotransmitter acetylcholine; the relative lack of dopamine causes an imbalance between the two and is responsible for some of the signs and symptoms (rigidity, resting tremor, and bradykinesia/akinesia). The pathophysiology of Parkinson disease does not involve dopamine excess or limpness. p. 380
A nurse is teaching the staff about causes for cranial nerve palsies. Which causes should the nurse include? Multiple selection question Tumor Aneurysm Polymyositis Tuberculosis Spinal shock
Tumor Aneurysm Tuberculosis Causes of cranial nerve palsies include tuberculosis, vascular occlusion, hemorrhage, tumors, and aneurysms. Cranial nerve nuclear palsies are not caused by polymyositis or spinal shock. Polymyositis affects the lower motor neurons; spinal shock predominantly affects spinal cord functions below the lesion. p. 384
