Ch69 Management (Neurological Infections, Autoimmune Disorders, and Neuropathies)

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?" "Have you experienced any ptosis in the last few weeks?" "Have you had difficulty with urination in the last 6 weeks?" "Have you developed any new allergies in the last year?"

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

In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter?

ACh

Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine Acetylcholine Gamma-aminobutyric acid

Acetylcholine

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Muscle weakness and hyporeflexia of the lower extremities Fever and cough Hyporeflexia and skin rash Ptosis and muscle weakness of upper extremities

Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? Avoid hot temperatures. Avoid physical activity. Take moderate amounts of alcohol. Avoid analgesic medication.

Avoid hot temperatures

the nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? Assess facial weakness 5 minutes after injection. Ensure atropine is readily available. Administer edrophonium chloride per orders. Document the results.

ensure atropine is readily available

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients? Gag reflex and bowel sounds Condition of skin Respiratory status Urinary output and capillary refill

Gag reflex and bowel sounds

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? No treatment unless the roommate begins to show symptoms Treatment with antimicrobial prophylaxis as soon as possible Admission to the nearest hospital for observation Bedrest at home for 72 hours

Treatment with antimicrobial prophylaxis as soon as possible People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? Vision changes Absent deep tendon reflexes Tremors at rest Flaccid muscles

Vision changes

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 the body does not have enough immunoglobulins A disorder in which the body has too many immunoglobulins A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" A disorder in which histocompatible cells attack the immunoglobulins

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

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? "I was taking a bath." "I was sitting at home watching television." "I was brushing my teeth." "I was putting my shoes on."

"I was brushing my teeth." Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply. Administration of rifampin Administration of ciprofloxacin hydrochloride Administration of ceftriaxone sodium Amoxicillin Rofecoxib

Administration of rifampin Administration of ciprofloxacin hydrochloride Administration of ceftriaxone sodium

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems? Frontal lobe abscess Temporal lobe abscess Cerebellar abscess Wernicke's abscess

Cerebellar abscess

A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario? Avonex Betaseron Copaxone Novantrone

Copaxone Copaxone reduces the rate of relapse in the RR course of MS. decreases the # of plaques noted on MRI and increases the time between relapses. -subQ daily. -acts by increasing the antigen-specific suppressor T cells. - SE and injection site reactions are rare. -may take 6 months for evidence of an immune response to appear.

The primary arthropod vector in North America that transmits encephalitis is the tick. horse. mosquito. flea.

Mosquito

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply. Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia Hypothermia

Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for A. signs and symptoms of cardiac insufficiency. B. signs of relapse. C. signs of improvement in the patient's condition. D. renal complications related to acyclovir therapy.

Renal complications related to acyclovir therapy Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform? Apply warm packs to the affected area. Relax in a hot bath. Exercise following a circuit training regimen. Avoid swimming and any weight-bearing activity.

apply warm packs to the affected area

Which is often the most disabling clinical manifestation of multiple sclerosis? Pain Fatigue Spasticity Ataxia

fatigue Fatigue affects 87% of people with MS, and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are other clinical manifestations of MS, but are not the most disabling.

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Renal Hepatic

renal Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45 The nurse should administer 45 drops/minute. The formula is to divide 180 ml by 60 minutes, which yields 3 ml/minute; 3 ml/minute × 15 drops = 45 drops/minute.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? Encourage the client to close his eyes. Alternatively patch one eye every 2 hours. Turn out the lights in the room. Instill artificial tears.

Alternatively patch one eye every 2 hours Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

While caring for clients who have suffered neuro deficits from causes such as CVA and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: complications. falls. choking. infection.

Complications Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.

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? Multiple sclerosis Creutzfeldt-Jakob disease Parkinson disease Huntington disease

Creutzfeldt-Jakob disease

Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis? Polymerase chain reaction (PCR) Electroencephalogram (EEG) Cerebrospinal fluid (CSF) exam Lumbar puncture

Polymerase chain reaction (PCR) its a virus

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Tensilon test CT EMG Serum studies

Tensilon test

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? Warm, dry skin Urine output of 40 ml/hour Soft, nondistended abdomen Uneven, labored respirations

Uneven, labored respirations A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by uneven, labored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply. respiratory distress increasing ICP seizure activity difficulty swallowing

respiratory distress difficulty swallowing

most common cause of acute encephalitis in the United States?

herpes simplex virus (HSV)

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 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 respiratory rate and oxygen saturation. Assess the blood pressure and heart rate. Assess the peripheral pulses. Listen to the bowel sounds.

Assess the blood pressure and heart rate.

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 Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Fatigue and depression

Facial pain in the areas of the fifth cranial nerve

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? Use pressure-relieving devices when the client is in bed or in a wheelchair. Change body position every 2 hours. Help the client perform range-of-motion (ROM) exercises every 8 hours. Use a footboard and trochanter rolls.

Help the client perform range-of-motion (ROM) exercises every 8 hours.

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Blood pressure apparatus Nebulizer and thermometer Incentive spirometer Intubation tray and suction apparatus

Intubation tray and suction apparatus

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario? Valium Zanaflex Lioresal Dantrium

Lioresal Baclofen (Lioresal), a gamma-aminobutyric acid (GABA) agonist, is the medication of choice for treating spasticity. It can be administered orally or by intrathecal injection.

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? Maintains effective respirations and airway clearance Shows increasing mobility Receives adequate nutrition and hydration Demonstrates recovery of speech

Maintains effective respirations and airway clearance

Which reflects basic nursing measures in the care of the client with viral encephalitis? Providing comfort measures Administering narcotic analgesics Administering amphotericin B Monitoring cardiac output

Providing comfort measures

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? Avoid stimuli that trigger pain. Use ophthalmic lubricant and protect the eye. Encourage semiannual dental exams. Complete the course of antibiotics as prescribed.

Use ophthalmic lubricant and protect the eye.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? Change in level of consciousness Vomiting Vector bites Seizures

Vector bites

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? Avoid analgesic medication. Take moderate amounts of alcohol. Avoid hot temperatures. Avoid physical activity.

avoid hot temperatures

A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with: dysarthria. dysphasia. ataxia. dysphagia.

dysarthria.

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

positive brudinski sign

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?" "Have you experienced any ptosis in the last few weeks?" "Have you had difficulty with urination in the last 6 weeks?" "Have you developed any new allergies in the last year?"

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

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days 2 hours prior to the administration of antibiotics for 7 days 1 hour after the antibiotic has infused and daily for 7 days It can be administered every 6 hours for 10 days.

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following? 20/20 vision Bulbar weakness Blindness Inability to swallow

20/20 vision

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. Exercise the right eye twice a day. Administer eye drops as needed. Place needed items on the right side.

Apply an eye patch to the right eye.

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

Atropine

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority? Provide instruction on blood-thinning medication. Praise client when using adaptive equipment. Include client in planning of care and setting of goals. Assess client for ability to ambulate independently.

Include client in planning of care and setting of goals

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? Sleep pattern Mood and affect Appetite Muscle spasms

Muscle spasms

A client is scheduled to receive Gamma Knife therapy. The nurse interprets this as which form of therapy? Stereotactic radiosurgery Surgical resection External beam radiation therapy Open biopsy

Stereotactic radiosurgery Gamma Knife is a form of stereotactic radiosurgery, where precise beams of radiation produce a targeted approach of concentrated radiation for the brain, head, and neck. It is not considered surgical resection, external beam radiation therapy, or an open biopsy.

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

facial Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve.

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? Assess for facial weakness. Initiate seizure precautions. Assess visual acuity. Ensure that client takes nothing by mouth.

Initiate seizure precautions

Which of the following is the first-line therapy for myasthenia gravis (MG)? Deltasone (Prednisone) Azathioprine (Imuran) Lioresal (Baclofen) Pyridostigmine bromide (Mestinon)

Pyridostigmine bromide (Mestinon)

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Respiratory Gastrointestinal Urinary Skin

Respiratory

A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor? Streptococcus pneumoniae Escherichia coli Hemophilus influenzae Staphylococcus aureus

Streptococcus pneumoniae

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? The client will take the seizure medication at the same time daily. The client will remain free of injury if a seizure does occur. The client will verbalize an understanding of feelings that preempt seizure activity. The client will post emergency numbers on the refrigerator for ease of obtaining.

The client will remain free of injury if a seizure does occur.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? Bell's palsy Angina pectoris Trigeminal neuralgia Migraine headache

Trigeminal neuralgia

A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: genetic dysfunction. upper and lower motor neuron lesions. decreased conduction of impulses in an upper motor neuron lesion. a lower motor neuron lesion.

a lower motor neuron lesion. MG is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneuronal jxn. is not a genetic disorder combined upper and lower motor neuron lesion occurs as result of spinal injuries. lesions involving CN and their axons

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? Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Facial distortion and pain Fatigue and depression

facial distortion and pain

A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for mood changes and fluid and electrolyte alterations. renal insufficiency. hypoxia. leukopenia and cardiac toxicity.

leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lymphoma but is also used to treat secondary progressive MS. Clients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity.

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? "I will take hot tub baths to decrease spasms." "I should participate in non-weight-bearing exercises." "I will stretch daily as directed by the physical therapist." "The exercises should be completed quickly to reduce fatigue."

"I will stretch daily as directed by the physical therapist." A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.

The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood? A donor with a history of hypertension with a blood pressure of 140/90 mm Hg A donor who is taking medication for benign prostatic hyperplasia A donor who moved to the United States from Canada A donor who was in college in England for 1 year

A donor who was in college in England for 1 year The prion exists in lymphoid tissue and blood in both Variant Creutzfeldt-Jakob Disease (vCJD) and Creutzfeldt-Jakob Disease (CJD). Both prion diseases are believed to be bloodborne. No method is available to screen blood for infectivity. For this reason, the American Red Cross will not accept blood donation from anyone who has traveled to the United Kingdom or Europe for more than 3 to 6 months

A client is suspected to have bacterial meningitis. What is the priority nursing intervention? Administer prescribed antibiotics. Encourage oral fluid intake. Prepare the client for a CT scan. Assess the CSF fluid laboratory test results.

Administer prescribed antibiotics.

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. Only a very small percentage (5% to 8%) of clients recover completely. Usually 100% of clients recover completely. No one with Guillain-Barre syndrome recovers completely.

Approximately 60% to 75% of clients recover completely.

Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support

Assessing respiratory effort

Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support

Assessing respiratory effort

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

Bacteria Septic meningitis is caused by bacteria. aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.

The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing? Brain abscess Strep throat infection Otitis media Damage to cranial nerve V

Brain Abscess A brain abscess can result from intracranial surgery, penetrating head injury, or tongue piercing. The other choices are not associated with tongue piercing.

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis? Preventing renal insufficiency Controlling seizures and increased intracranial pressure Maintaining hemodynamic stability and adequate cardiac output Preventing muscular atrophy

Controlling seizures and increased intracranial pressure

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. Decreased glucose Increased protein Increased white blood cells Decreased protein Increased glucose

Decreased glucose Increased protein Increased white blood cells

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply. Have the patient take a hot tub bath to allow muscle relaxation. Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Assist with a rigorous exercise program to prevent contractures.

Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises

Bell palsy is a disorder of which cranial nerve?

Facial (VII) Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Meniere syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barre syndrome is a disorder of the vagus nerve.

The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? Headache that is worse in the morning Ptosis that is more pronounced at the end of the day Diplopia that is constant Nuchal rigidity

Headache that is worse in the morning The most prevailing symptom of a brain abscess is headache, which is usually worse in the early morning. Ptosis and diplopia are seen in clients with myasthenia gravis. Nuchal rigidity is seen in clients with meningitis.

Most common cause of acute encephalitis in the US

Herpes simplex virus (HSV) Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States.

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. Ensure the family receives prophylaxis antibiotic treatment. Administer prescribed antibiotics. Apply a cooling blanket.

Initiate isolation precautions

The diagnosis of multiple sclerosis is based on which test? Cerebrospinal fluid (CSF) electrophoresis Magnetic resonance imaging (MRI) Evoked potential studies Neuropsychological testing

Magnetic resonance imaging (MRI) The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed on MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Hyporeflexia and skin rash Ptosis and muscle weakness of upper extremities Fever and cough Muscle weakness and hyporeflexia of the lower extremities

Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? An elevated acetylcholine receptor antibody titer Episodes of muscle fasciculations IV administration of edrophonium Oligoclonal bands

Oligoclonal bands

The most common cause of cholinergic crisis includes which of the following? Overmedication Infection Undermedication Compliance with medication

Overmedication

The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe? Ptosis and diplopia Muscle weakness and hyporeflexia of the lower extremities Difficulty with urination Facial distortion and pain

Ptosis and diplopia

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Hepatic Renal

Renal Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

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 Carries message to the next nerve cell Represents building block of nervous system Acts as chemical messenger

Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

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. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.

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

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. Kernig's sign. a positive sweat chloride test. Brudzinski's sign.

a positive edrophonium (Tensilon) test

A neurologic deficit is best defined as a deficit of the: central and peripheral nervous systems with decreased, impaired, or absent functioning. central nervous system that affects one body system. central nervous system with absent functioning. peripheral nervous system with decreased or impaired functioning.

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

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms indicate renal toxicity and a worsening condition. are primarily associated with infection with Coccidioides immitis and Aspergillus. indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin.

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine and acetaminophen approximately 30 minutes before the administration of amphotericin B may prevent these side effects.

The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include sensory disturbance, limb pain, and behavioral changes. muscle rigidity, memory impairment, and cognitive impairment. diplopia and bradykinesia. akathisia and dysphagia.

sensory disturbance, limb pain, and behavioral changes.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Sphygmomanometer Padded tongue blade Nasal cannula and oxygen Suction machine with catheters

suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside.

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct? "The client may be experiencing a change in affect due to the brain injury." "The client has demonstrated this behavior before and is now anticipated." "The client has underlying aggression problems, which manifest in behavior." "All traumatic brain injury clients act in this similar way."

"The client may be experiencing a change in affect due to the brain injury."

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 Numbness Patchy blindness Loss of proprioception

Diplopia and ptosis

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 Numbness Patchy blindness Loss of proprioception

Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis

The diagnosis of multiple sclerosis is based on which test?

MRI

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." "You'll be permanently paralyzed; however, you won't have any sensory loss." "It must be hard to accept the permanency of your paralysis." "You'll first regain use of your legs and then your arms."

"The paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

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? "Don't worry; your child will be fine." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." "It's too early to give a prognosis."

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

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? "You should take your medications only during times of relapse." "You must avoid stress and extreme fatigue, because these can trigger a relapse." "You will have a steady and gradual decline in function." "Your type of MS is the least common, making it difficult to manage."

"You must avoid stress and extreme fatigue, because these can trigger a relapse." Stress, fatigue, and temperature extremes can trigger relapses of MS. The client should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Clients taking MS medications should take them on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque from forming on the brain and spinal cord. RRMS is characterized by states of remission and relapses. A steady decline in function is consistent with primary progressive MS. RRMS is the most common type, and many treatments are available.

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. Request that the patient be cared for by another nurse. Discontinue the bath and resume it later. Explain that the client is getting good care.

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

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? Pyridostigmine (Mestinon) Carbachol (Carboptic) Edrophonium (Tensilon) Ambenonium (Mytelase)

Edrophonium (Tensilon) Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? Assess facial weakness 5 minutes after injection. Ensure atropine is readily available. Administer edrophonium chloride per orders. Document the results.

Ensure atropine is readily available Atropine should be ready before administration of edrophonium chloride so it is available if needed to control the side effects of the medication. Assessing facial weakness and documenting the results occur after the administration of edrophonium chloride; therefore, they are not the priority interventions.

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 Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Fatigue and depression

Facial distortion and pain Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Decreased pulse rate, respirations of 20 breaths/minute Increased pulse rate, adventitious breath sounds Increased pulse rate, respirations of 16 breaths/minute Decreased pulse rate, abdominal breathing

Increased pulse rate, adventitious breath sounds An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.

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? Parkinson disease Huntington disease Creutzfeldt-Jakob disease Multiple sclerosis

Multiple Sclerosis The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? Negative Kernig's sign Positive Brudzinski's sign Increased intake Hyper-alertness

Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? Negative Kernig's sign Positive Brudzinski's sign Increased intake Hyper-alertness

Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? Positive Kernig's sign Negative Brudzinski's sign Positive Romberg sign Hyper-alertness

Positive Kernigs sign A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.

Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? Administering amphotericin B Preparing for organ donation Initiating isolation procedures Providing palliative care

Providing palliative care vCJD is a progressive fatal disease; no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

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 applying cool compresses on the face several times a day to tighten the muscles. Tell the patient to smile every 4 hours. Inform the patient that the muscle function will return as soon as the virus dissipates. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

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

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? The client grasps the affected arm at the wrist and raises it. The client arranges a community service to deliver meals. The client ambulates with the assistance of one. The client uses a mechanical lift to climb steps.

The client grasps the affected arm at the wrist and raises it.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at preventing renal insufficiency. controlling seizures and increased intracranial pressure. maintaining hemodynamic stability and adequate cardiac output. preventing muscular atrophy.

controlling seizures and IICP

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: increase the dose of muscle relaxants. rest in an air-conditioned room. take a hot bath. avoid naps during the day.

rest in air conditioned room Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

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 hrs after exposure People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.