Chapter 42 - Care of Patients with Problems of the Central Nervous System: The Brain

The spouse of the client with Alzheimer's disease is listening to the home health nurse explain the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. "Rivastigmine (Exelon) is used to treat depression." "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." The comment that shows that the spouse understands the nurse's instructions is that Aricept will treat symptoms of Alzheimer's. Cholinesterase inhibitors (e.g., donepezil) are approved for the symptomatic treatment of Alzheimer's disease. This class of medication delays the destruction of acetylcholine (ACh) by the enzyme cholinesterase.Memantine (Namenda) is indicated for advanced Alzheimer's disease. Memantine blocks excess amounts of glutamate which can damage nerve cells. Rivastigmine (Exelon) is a cholinesterase inhibitor that is used to treat Alzheimer's symptoms. Selective serotonin reuptake inhibitors like sertraline (Zoloft) are antidepressants and may be used in Alzheimer's clients who develop depression.

The nurse is teaching a client, newly diagnosed with migraines, about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? "I can still eat Chinese food." "I must not miss meals." "It is okay to drink a few wine coolers." "I need to use fake sugar in my coffee."

"I must not miss meals." The client understands the teaching plan about trigger control for migraines when the client states that he/she must not miss meals. Until triggers are identified, a headache diary would be considered. Missing meals is a trigger for many people suffering from migraines. The client must not skip any meals until the triggers are identified.Chinese food frequently contains monosodium glutamate. Monosodium glutamate-containing foods, alcohol, and artificial sweeteners are triggers for many people suffering from migraines and need to be eliminated until the triggers are identified.

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? "Birth control is not needed while taking sumatriptan." "I must report any chest pain right away." "St. John's wort can also be taken to help my symptoms." "Sumatriptan can be taken as a last resort."

"I must report any chest pain right away." The client comment that shows that she understands the discharge instructions is that any chest pain must be reported right away. Chest pain must be reported immediately with the use of sumatriptan because triptans cause vasoconstriction.Remind the client to use contraception (birth control) while taking the drug because it may not be safe for women who are pregnant. Triptans would not be taken with selective serotonin reuptake inhibitors or St. John's wort, an herb used commonly for depression. Sumatriptan must be taken as soon as migraine symptoms appear.

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? Administer phenytoin (Dilantin). Draw the client's blood. Establish an airway. Start an intravenous (IV) line.

Establish an airway. When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? Select all that apply. Alopecia Headaches Dizziness Diplopia Increased blood glucose

Headaches Dizziness Diplopia Adverse effects the nurse must monitor for in a client taking carbamazepine for partial seizures after encephalitis include: headaches, dizziness, and diplopia. Carbamazepine affects the central nervous system, although it's mechanism of action is unclear.Carbamazepine does not cause alopecia and does not increase blood glucose. Divalproex (Depakote) and valproic acid (Depakene) may cause alopecia.

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? Potential for injury related to chronic confusion and physical deficits Risk for reduced mobility related to progression of disability Potential for skin breakdown related to immobility and/or impaired nutritional status Lack of social contact related to personality and behavior changes

Potential for injury related to chronic confusion and physical deficits The priority client problem related to a client admitted to the surgical unit for biopsy is the potential for injury due to chronic confusion and physical deficits. The most important intervention for interdisciplinary care is safety. Chronic confusion and physical deficits place the client with Alzheimer's disease at high risk for injury.Reduced mobility, skin breakdown, and lack of social contact, although potential problems in this population, are more frequently observed in the long-term setting and not the top priority.

A client receiving propranolol (Inderal) as a preventative for migraine headaches is experiencing side effects after taking the drug. Which side effect is of greatest concern to the nurse? Dry mouth Slow heart rate Tingling feelings Warm sensation

Slow heart rate The side effect that is the greatest concern for a client taking propranolol for migraine headaches is a slow heart rate. Beta blockers such as propranolol (Inderal) may be prescribed as a preventive medication for migraines. Propranolol causes blood vessels to relax and improves blood flow although the exact mechanism of action in migraines is unclear. The client would be taught how to monitor his or her heart rate and appropriately report any deviations to the primary care provider.Dry mouth is typically associated with tricyclic antidepressants such as nortriptyline. Skin flushing, tingling feelings, and a warm sensation are common side effects with triptan medications and are not indications to avoid using this group of drugs. Nortriptyline may be used as a preventive medication. Triptans are utilized as abortive medications after a migraine begins.

The nurse's friend fears that something is wrong with his grandmother, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? "Have you taken her for a check-up?" "She has Alzheimer's disease." "That is a normal part of aging." "You should look into respite care."

"Have you taken her for a check-up?" The best response by the nurse to a friend whose grandmother is forgetful and wandering is to ask her friend if he/she has taken the grandmother for a check-up. The grandmother's symptoms could indicate possible Alzheimer's disease or some other physiologic imbalance, and she needs to be assessed further by the primary care provider.The nurse's role is not to diagnose Alzheimer's disease but to advocate for the friend's grandmother to be evaluated. Becoming extremely forgetful, disoriented, and wandering is not normal age related behavior. Respite care is for caregivers, not for clients.

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? "Can't you take care of your spouse?" "Establishing goals and a daily plan can help." "Make sure you take some time off and take care of yourself too." "That's not a very nice thing to say."

"Make sure you take some time off and take care of yourself too." The nurse's best response to the spouse of the client with dementia is to encourage the wife to take some time off to take care of herself. This response is supportive and reminds the spouse that he or she cannot care for the client when exhausted.Questioning the spouse's ability to provide care is not supportive and may offend the spouse. Establishing goals and a daily plan may be helpful to the situation but is not responding to the spouse's need. Reprimanding the spouse does not validate his or her feelings and does not allow the nurse to further explore the statement.

A client newly diagnosed with Parkinson disease (PD) is being discharged. Which instruction is best for the nurse to provide to the client's spouse? Administer medications promptly on schedule to maintain therapeutic drug levels. Complete activities of daily living for the client. Provide high-fiber, high-carbohydrate foods. Speak loudly for better understanding.

Administer medications promptly on schedule to maintain therapeutic drug levels. Administering medications promptly on schedule is a correct statement.The best instruction the nurse can give to the spouse of a PD client about to be discharged is to give schedule medications promptly in order to keep drug levels therapeutic.

A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? Allow the client to remain undisturbed. Assess the client's vital signs. Remove the cloth because it can harbor microorganisms. Turn on the lights for a neurologic assessment.

Allow the client to remain undisturbed. The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening.Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? Arranges for respite care Provides positive reinforcement and support to the wife Restrains the client for a short time each day, to allow the wife to rest Teaches the client improved self-care

Arranges for respite care The home health nurse can help relieve caregiver stress for the wife caring for her husband with Alzheimer's disease by arranging for respite care for the wife. Respite care can give the wife some time to reenergize and will provide a social outlet for the client.Providing positive reinforcement and support is important but does not help provide a solution to the wife's situation. Restraints are almost never appropriate and are used only as a last resort. The client with Alzheimer's disease typically is unable to learn improved self-care.

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? Assessing neurologic status at least every 2-4 hours Decreasing environmental stimuli Managing pain through drug and nondrug methods Strict monitoring of hourly intake and output

Assessing neurologic status at least every 2-4 hours The highest priority nursing intervention for the newly admitted client with bacterial meningitis is to accurately monitor and record the client's neurologic status every 2-4 hours. The neurologic status, vital signs, and vascular status must be assessed at least every 4 hours or more often, if clinically indicated, to rapidly determine any deterioration in status.Decreasing environmental stimuli is helpful for the client with bacterial meningitis but is not the highest priority. Clients with bacterial meningitis report severe headaches requiring pain management which may be accomplished through both pharmacologic and nonpharmacologic methods. Assessing fluid balance while preventing overload is not the highest priority however intake and output must be monitored.

A client is being discharged to home with progressing stage I Alzheimer's disease. The family expresses concern to the nurse about caring for their parent. What is the priority for best continuity of care? Assigning a case manager Ensuring that all family questions are answered before discharge Providing a safe environment Referring the family to the Alzheimer's Association

Assigning a case manager The priority for the best continuity of care for a client about to be discharged with progressing Stage I Alzheimer's disease is to assign a case manager to the client and family. Whenever possible, the client and family need the services of a case manager who can assess their needs for health care resources and facilitate appropriate placement throughout the continuum of care. Continuity of care is important through all stages of Alzheimer's disease.Ensuring all questions are answered and providing a safe environment are necessary for family support. The Alzheimer's Association will also be able to help provide information and support to the family.

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? Assuming that the client is not totally confused Providing the client with several options to choose from Waiting for the client to express a need Writing down instructions for the client

Assuming that the client is not totally confused The best communication technique to use for a client with advanced Alzheimer's disease is to not assume that the client is totally confused and cannot understand what is being said.Choices need to be limited. Too many choices cause frustration and increased confusion in the client. Rather than waiting for the client to express a need, try to anticipate the client's needs and interpret nonverbal communication. Just writing down instructions may be confusing for the client. It is better to provide the client instructions with pictures, and put them in a highly visible place.

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for prevention of migraines. The nurse plans to contact the primary care provider (PCP) if the client has which condition? Bipolar disorder Diabetes mellitus Glaucoma Hypothyroidism

Bipolar disorder The nurse contacts the PCP after reviewing the history of a client with bipolar disorder who has been prescribed topiramate. Cases of suicide have been associated with topiramate when it is used in larger doses of 400 mg daily, most often in clients with bipolar disorder.Topiramate is not contraindicated in clients with diabetes mellitus, glaucoma, or hypothyroidism.

A client is admitted into the emergency department (ED) with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? Classic migraine Meningitis Stroke West Nile virus

Classic migraine The nurse suspects that a classic migraine could be present when an ED client complains of frontal-temporal pain preceded by a visual disturbance. These symptoms are most typical of a classic migraine.Meningitis may present with a headache and visual disturbance but is usually accompanied by nuchal rigidity (neck stiffness) and fever. The symptoms of stroke will vary depending upon the area affected. Mild cases of West Nile virus may be asymptomatic or present with flu-like symptoms, whereas severe cases may lead to loss of consciousness and death.

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? Cloudy, turbid CSF Decreased white blood cells Decreased protein Increased glucose

Cloudy, turbid CSF Cloudy, turbid CSF indicates to the nurse that the client may have bacterial meningitis.Clear fluid is a sign of viral meningitis. Increased white blood cells, increased protein, and decreased glucose are signs of bacterial meningitis.

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? Avoid large crowds. Get the meningococcal vaccine. Take a high dose vitamin C daily. Take prophylactic antibiotics.

Get the meningococcal vaccine. The most effective way for a college student to minimize the risk for bacterial meningitis is to get the meningococcal vaccine. Individuals ages 16-21 years have the highest rates of meningococcal infection and need to be immunized against the virus.Avoiding large crowds is helpful, but is not practical for a college student. Taking a high dose of vitamin C every day does not minimize the risk of bacterial meningitis. However, maintaining a healthy lifestyle, with adequate sleep and nutrition, can improve immunity. Taking prophylactic antibiotics is inappropriate because it leads to antibiotic-resistant strains of microorganisms.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Apple juice Grape juice Grapefruit juice Prune juice

Grapefruit juice The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin (Dilantin).

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. Bite block at the bedside Intravenous access (IV) Continuous sedation Suction equipment at the bedside Siderails raised

Intravenous access (IV) Suction equipment at the bedside Siderails raised Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.

A client with Parkinson disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? Involving the client and his wife in developing a plan of care Setting up visitations by a home health nurse Telling his wife what the client needs Writing up a detailed plan of care according to standards

Involving the client and his wife in developing a plan of care The discharge plan most effective when discharging a client home with his spouse is to involve both the client and his wife in developing the plan of care. Involving the client and spouse in drawing up a plan of care is the best way to ensure success with the management plan.Home health nurse visitations are generally helpful but may not be needed for this client. The management plan must be collaborative and include not only the spouse but the client to ensure buy-in. Evidence-based guidelines would be utilized.

A client has Parkinson's disease (PD). Which nursing intervention best protects the client from injury? Discouraging the client from activity Encouraging the client to watch the feet when walking Monitoring the client's sleep patterns Suggesting that the client obtain assistance in performing activities of daily living (ADLs)

Monitoring the client's sleep patterns The nursing intervention that best protects the PD client from injury is to monitor the client's sleep patterns. Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).Active and passive range-of-motion exercises, muscle stretching, and activity are important to keep the client with PD mobile and flexible. The client with PD needs to avoid watching his or her feet when walking to prevent falls and would be encouraged to participate as much as possible in self-management, including ADLs. Occupational and physical therapists can provide training in ADLs and the use of adaptive devices, as needed, to facilitate independence.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? Documents the length and time of the seizure. Forces a tongue blade in the mouth. Positions the client on the side. Restrains the client.

Positions the client on the side. When a newly admitted client with a history of seizures begins to seize, the nurse must turn the client on his/her side. Turning the client on the side during a generalized tonic-clonic or complex partial seizure is indicated because he or she may lose consciousness resulting in potential loss of a patent airway.Documenting the length and time of seizures is important, but not the priority intervention. Both forcing a tongue blade in the mouth and restraining the client can cause injury.

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? Alzheimer's Wandering Association Lost Family Members Tracking Association National Alzheimer's Group Safe Return Program

Safe Return Program The discharge nurse suggests the Safe Return Program to the daughter of a client who wanders at home. The Safe Return Program, a national, government-funded program of the Alzheimer's Association assists in the identification and safe, timely return of those with dementia who wander off and become lost.The Alzheimer's Wandering Association, National Alzheimer's Group, and Lost Family Members Tracking Association do not exist.

The nurse has received report on a group of clients. Which client requires the nurse's attention first? Adult who is lethargic after a generalized tonic-clonic seizure Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

Young adult who has experienced four tonic-clonic seizures within the past 30 minutes After receiving report on a group of clients, the nurse first needs to attend to the young adult client who is experiencing repeated seizures over the course of 30 minutes. This client is in status epilepticus, which is a medical emergency and requires immediate intervention.The adult client who is lethargic and the middle-aged adult client with absence seizures do not require immediate attention. A fever of 101.9° F (38.8° C), although high, does not require immediate attention.