Ch 69

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon)

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Antibodies are removed from the plasma.

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers."

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?"

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye.

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?

Approximately 60% to 75% of clients recover completely.

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?

Assess the blood pressure and heart rate.

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?

Bacteria

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available?

Equipment to maintain infection control precautions

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?

Headache and nuchal rigidity

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions.

The diagnosis of multiple sclerosis is based on which test?

MRI

Which is the primary vector of arthropod-borne viral encephalitis in North America?

Mosquitoes

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?

Multiple sclerosis

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

Multiple sclerosis

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

The most common cause of cholinergic crisis includes which of the following?

Overmedication

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?

Providing supportive care

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following?

Systemic lupus erythematous

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?

Vision changes

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?

preventing further neurologic damage