Chapter 37: Caring for Clients with Central and Peripheral Nervous System Disorders

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 brushing my teeth." p. 623.

The nurse is caring for a client diagnosed with Parkinson disease. The client is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the client to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? Sitting quietly on the toilet every 2 hours Use of a raised toilet seat Use of a bedpan Following the outlined bowel program

Use of a raised toilet seat p. 629

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: place an oral airway in the client's mouth to maintain an open airway. allow the client to remain in the chair but move all objects out of his way. hold the client's arm still to keep him from hitting anything. carefully move the client to a flat surface and turn him on his side.

carefully move the client to a flat surface and turn him on his side. pp. 635-636

What is one of the earliest signs of increased ICP? Cushing's triad decreased level of consciousness (LOC) headache coma

decreased level of consciousness (LOC) p. 608.

The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Venous Doppler studies Lumbar puncture Computed tomography (CT) scan Magnetic resonance imaging (MRI)

Lumbar puncture

A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication? Mannitol Furosemide Spironlactone Hydrochlorothiazide

Mannitol p. 638

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 12 9 3 6

3 p. 608

Which value indicates a normal intracranial pressure (ICP)?

5 mm Hg p. 607.

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

Assessing respiratory effort p. 620.

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Bradypnea Tachycardia Hypertension Bradycardia Pupillary constriction

Bradycardia Bradypnea Hypertension pp. 608-609

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? Fluid restriction Transfusion of fresh frozen plasma (FFP) Transfusion of platelets Electrolyte restriction

Fluid restriction

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? High in protein and low in carbohydrate Low in fat At least 50% carbohydrate Restricts protein to 10% of daily caloric intake

High in protein and low in carbohydrate

The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? Instruct the client on daily muscle stretching. Provide total assistance with all ADLs. Encourage the client to void every hour. Order a low-residue diet.

Instruct the client on daily muscle stretching. p. 618

A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing? Cranial arteritis Paroxysmal hemicranias Secondary headache

Secondary headache pp. 607-609.

A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond? "Let's explore other options, because laxatives can have side effects and create dependency." "Make sure that you supplement your laxatives with a nutritious diet." "You should ideally be using herbal remedies rather than medications to promote bowel function." "It's important to drink plenty of fluids while you're taking laxatives."

"Let's explore other options, because laxatives can have side effects and create dependency." p.626

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize? Focal seizure Generalized seizure Unclassified seizure Absence seizure

Generalized seizure pp. 631-632

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits? Dementia Slow, shuffling gait Dysphagia and dysphonia Rapid, jerky, involuntary movements

Rapid, jerky, involuntary movements p. 631

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering p. 609

The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? Administering tube feedings Providing ventilatory assistance Facilitating ABG analysis Suctioning secretions

Providing ventilatory assistance p. 620

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the Trendelenburg position. prone position with the head turned to the unaffected side. supine position with the head slightly elevated. dorsal recumbent position.

supine position with the head slightly elevated. p. 609

A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? Decreased muscle spasms in the lower extremities Promotion of urinary continence Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) Increased muscle strength in the upper extremities

Decreased muscle spasms in the lower extremities p. 618.

A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? Difficulty in coordination Personality changes Contractures Cognitive declines

Difficulty in coordination p. 618.

The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP? Disorientation and restlessness Loss of corneal reflex Projectile vomiting Decreased pulse and respirations

Disorientation and restlessness p. 608

A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply. Medication regimen Nutritional support Appointments for chemotherapy or radiotherapy Electromyography Adverse effects of chemotherapy or radiation and techniques for managing them

Medication regimen Appointments for chemotherapy or radiotherapy Adverse effects of chemotherapy or radiation and techniques for managing them Nutritional support p. 639

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Prednisone Dexamethasone Cafergot Phenytoin

Phenytoin p. 632

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. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates. Tell the patient to smile every 4 hours.

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. p. 625

The nurse teaches the client that corticosteroids will be used to treat his brain tumor to prevent extension of the tumor. facilitate regeneration of neurons. reduce cerebral edema. identify the precise location of the tumor.

reduce cerebral edema. p. 638.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Position the client with the head turned toward the side of the brain tumor. Provide sensory stimulation. Administer stool softeners. Encourage coughing and deep breathing.

Administer stool softeners. p. 610

A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease? Metastasis Risk for stroke Emotional and personality changes Pathologic bone fractures

Emotional and personality changes p. 631

Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field? Ensure a clutter-free walkway. Announce yourself when approaching the client. Instruct on adaptive plates with rims. Place patient in a room near the nursing station.

Ensure a clutter-free walkway. p. 621.

A client is recovering from intracranial surgery performed approximately 24 hours ago and is reporting a headache that the client rates at 8 on a 10-point pain scale. What nursing action is most appropriate? Apply a hot pack to the client's scalp. Implement distraction techniques. Reposition the client in a prone position. Administer morphine sulfate as prescribed.

Administer morphine sulfate as prescribed.

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? Recent weight gain and loss Compliance with the prescribed medication regimen Recent stress level The type of anticonvulsant prescribed to manage the epileptic condition

Compliance with the prescribed medication regimen p. 635.

The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Pain at the base of the tongue Facial paralysis Diplopia

Facial paralysis pp. 324 - 325

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? Sensory Absence Generalized Jacksonian

Generalized pp. 631-632

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition? Bowel incontinence Chronic confusion Impaired urinary elimination Impaired verbal communication

Impaired verbal communication p.620

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Infection Increased ICP Increase in cerebral perfusion pressure Exacerbation of uncontrolled hypertension

Increased ICP pp. 607-609

The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? Increased muscle strength Decreased pain Improved cognition Improved GI function

Increased muscle strength pp. 619 - 620.

A nurse is reading a journal article about spinal cord tumors and metastasis from other primary sites. The nurse demonstrates understanding of the article when identifying which primary sites as commonly metastasizing to the spinal cord? Select all that apply. Bladder Gastrointestinal tract Breast Prostate Lung

Lung, Breast, Gastrointestinal tract pp. 637 - 638

The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis? Monitor arterial blood gas (ABG) values. Change the client's position as indicated. Monitor serum electrolytes. Maintain NPO status.

Monitor serum electrolytes.

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 Huntington disease Parkinson disease Creutzfeldt-Jakob disease

Multiple sclerosis p. 617

When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Anemia Obesity Osteoporosis Osteoarthritis

Osteoporosis

A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by the diagnosis and the known complications of the disease. How can the client best make known their wishes for care as the disease progresses? Ensure that witnesses are present when he provides instruction. Collaborate with representatives from the Amyotrophic Lateral Sclerosis Association. Designate a most responsible health care provider (MRP) early in the course of the disease. Prepare an advance directive.

Prepare an advance directive. p. 620

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Cardiac function Cognition Respiratory function Potential skin breakdown

Respiratory function p. 620.

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? Administering prescribed antipyretics Hyperoxygenation before and after tracheal suctioning Restricting fluid intake and hydration Maintaining adequate hydration

Restricting fluid intake and hydration p.613

A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? Minced foods and a fluid restriction Semisolid food with thick liquids Provision of a low-residue diet Total parenteral nutrition (TPN)

Semisolid food with thick liquids p. 686

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? The patient should perform frequent physical activity but avoid becoming fatigued. The patient should perform exercises that are brief but high-intensity. The patient should attempt to maintain prediagnosis levels of activity and mobility. The patient should prioritize energy conservation and remain on bed rest if possible.

The patient should perform frequent physical activity but avoid becoming fatigued. pp. 617-618.

A client fell while snowboarding, sustaining a blow to the head resulting in a loss of consciousness. Upon arrival at the emergency department, the client regained consciousness within 1 hour. What signs are symptoms would indicate increased ICP? Select all that apply. sleepiness nausea headache personality changes

personality changes sleepiness p. 608.