Chapter 46: Nursing Management: Patients With Neurologic Disorders

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered within normal limits. low. high. inaccurate.

low. Explanation: Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg. A CPP of 40 mm Hg is low.

Which is the primary vector of arthropod-borne viral encephalitis in North America? Mosquitoes Ticks Birds Spiders

mosquitoes Explanation: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.

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? No one with Guillain-Barre syndrome recovers completely. Usually 100% of clients recover completely. Only a very small percentage (5% to 8%) of clients recover completely. Approximately 60% to 75% of clients recover completely.

Approximately 60% to 75% of clients recover completely. Explanation: Results of studies on Guillain-Barre syndrome indicate that 60% to 75% of clients recover completely.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Patchy blindness Diplopia and ptosis Loss of proprioception Numbness

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

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 Explanation: 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.

One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? Compound forms Motor symptoms Sensory symptoms Impaired consciousness

Impaired consciousness Explanation: A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Demonstrates optimal cerebral tissue perfusion Maintains a patent airway Displays no signs or symptoms of infection

Maintains a patent airway Explanation: Maintenance of a patent airway is always a first priority. Loss of airway is a possible complication of increasing ICP, as well as aspiration from vomiting.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? Increased ability to sleep Relief from constipation Reduced muscle spasticity Relief from pain

Reduced muscle spasticity Explanation: Dantrolene reduces muscle spasticity. It doesn't increase the ability to sleep or relieve constipation or pain.

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? Sensory deficits in one arm Hypoactive bowel sounds Weakness and atrophy of the arm muscles Severe lower back pain

Severe lower back pain Explanation: The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.

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

Speeds nerve impulse transmission Explanation: 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.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is high. The CPP is low. The CPP is within normal limits. The CPP reading is inaccurate.

The CPP is low. Explanation: The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.

Which drug should be available to counteract the effect of edrophonium chloride? Atropine Prednisone Azathioprine Pyridostigmine bromide

A. Atropine Explanation: Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.

A client is admitted to the hospital with pneumonia. He has a history of Parkinson disease, which his family says is worsening. Which assessment should the nurse expect? Tremors in the fingers that increase with purposeful movement Muscle flaccidity Pleasant and smiling demeanor Impaired speech

Impaired speech Explanation: In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a masklike appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep.

A patient with herpes simplex virus (HSV) encephalitis has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? Ampicillin (Principen) Cyclobenzaprine (Flexeril) Cyclosporine (Neoral) Acyclovir (Zovirax)

Acyclovir (Zovirax) Explanation: Acyclovir (Zovirax), an antiviral agent, is the medication of choice in HSV treatment. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin is an antibiotic. Reference:

Which is a late sign of increased intracranial pressure (ICP)? Irritability Altered respiratory patterns Slow speech Headache

Altered respiratory patterns Explanation: Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

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

Assessing respiratory effort Explanation: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? "Avoid taking daytime naps." "Avoid hot baths and showers." "Limit your fruit and vegetable intake." "Restrict fluid intake to 1,500 ml/day."

"Avoid hot baths and showers." Explanation: The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

Which method is used to help reduce intracranial pressure? Using a cervical collar Keeping the head of bed flat Rotating the neck to the far right with neck support Extreme hip flexion, with the hip supported by pillows

Using a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Which phase of a migraine headache usually lasts less than an hour? Aura Headache Postdrome Premonitory

Aura Explanation: The aura phase occurs in about 20% of clients who have migraines and may be characterized by focal neurological symptoms. The premonitory phase occurs hours to days before a migraine headache. The headache phase lasts from 4 to 72 hours. During the postdrome phase, clients may sleep for extended periods.

The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? A. Hypokinesia B. Micrographia C. Dysphonia D. Dysphagia

Dysphonia Explanation: Dysphonia (voice impairment or altered voice production) may occur as a result of weakness and incoordination of the muscles responsible for speech.

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. Explanation: The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Labetalol Lamictal Lamisil Lomotil

Lamictal Explanation: Lamictal is an antiseizure medication. Its packaging was recently changed in an attempt to reduce medication errors, because this medication has been confused with Lamisil (an antifungal), labetalol (an antihypertensive), and Lomotil (an antidiarrheal).

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck, and he tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? Negative Brudzinski's sign Hyperactive patellar reflex Positive Kernig's sign Sluggish pupil reaction

Positive Kernig's sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Hyperactive patellar reflex and a sluggish pupil reaction are not common signs of meningitis.

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

Pyridostigmine bromide (Mestinon) Explanation: Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.

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? Respiratory function Cardiac function Potential skin breakdown Cognition

Respiratory function Explanation: Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment. Cardiac function and cognition are not normally affected by the disease.

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 Explanation: 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 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? "You'll be permanently paralyzed; however, you won't have any sensory loss." "You'll first regain use of your legs and then your arms." "It must be hard to accept the permanency of your paralysis." "The paralysis caused by this disease is temporary."

"The paralysis caused by this disease is temporary." Explanation: 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.

A client with Parkinson's disease asks the nurse what their treatment is supposed to do since the disease is progressive. What would be the nurse's best response? "Treatment aims at keeping you independent as long as possible." "Treatment aims at keeping you emotionally healthy by making you think you are doing something to fight this disease." "Treatment for Parkinson's is only palliative; it keeps you comfortable." "Treatment really doesn't matter; the disease is going to progress anyway."

"Treatment aims at keeping you independent as long as possible." Explanation: Treatment aims at prolonging independence. Treatment does matter, it is not palliative, and it is not aimed at keeping you emotionally healthy.

Cerebral edema peaks at which time point after intracranial surgery? 12 hours 24 hours 48 hours 72 hours

24 hours Explanation: Cerebral edema tends to peak 24 to 36 hours after surgery.

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect: Acute attacks with full recovery or residual deficit upon recovery. Progressive disability from onset. Acute attacks followed by progression at a variable rate. Progression with clear relapses with or without recovery.

Acute attacks with full recovery or residual deficit upon recovery. With relapsing-remitting multiple sclerosis, recovery is usually complete with each relapse. Residual deficits may occur and accumulate over time, contributing to a functional decline.

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? Administer stool softeners. Position the client with the head turned toward the side of the brain tumor. Encourage coughing and deep breathing. Provide sensory stimulation.

Administer stool softeners. Explanation: Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in a midline position and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Sensory stimulation and noxious stimuli can increase ICP.

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? Virus Bacteria Leukemia Lymphoma

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

Which signs are manifestations of the Cushing triad? Select all that apply. Bradypnea Hypertension Tachycardia Bradycardia

Bradypnea Hypertension Bradycardia Cushing triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

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 Explanation: There is no specific medication for arboviral encephalitis; therefore symptom management is key. Medical management is aimed at 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? Huntington disease Parkinson disease Creutzfeldt-Jakob disease Multiple sclerosis

Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis 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 is associated with decreased levels of dopamine due to 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.

The nurse is caring for a client with Parkinson disease (PD). Which finding in the client's medical record will cause the nurse to question giving a prescribed dose of benztropine mesylate? Narrow-angle glaucoma Type 2 diabetes Seizure disorder Hypotension

Narrow-angle glaucoma Explanation: Benztropine mesylate is an anticholinergic agent that is used to counteract the action of acetylcholine. This medication is contraindicated in clients with narrow-angle glaucoma. This medication is not contraindicated in hypotension, a seizure disorder, or type 2 diabetes.

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client? Severe depression Choreiform movements Urinary tract infection Emotional apathy

Urinary tract infection Explanation: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? Amiodarone (Cordarone) Carvedilol (Coreg) Metoprolol (Lopressor) Verapamil (Calan)

Verapamil (Calan) Explanation: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.

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 putting my shoes on." "I was taking a bath." "I was brushing my teeth." "I was sitting at home watching television."

"I was brushing my teeth." Explanation: 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 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? Cyclosporine (Sandimmune) Azathioprine (Imuran) Edrophonium (Tensilon) Immunoglobulin G (Iveegam EN)

Edrophonium (Tensilon) Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

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

High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? Creutzfeldt-Jakob disease Multiple sclerosis Parkinson disease Huntington disease

Multiple sclerosis Explanation: 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 CNS characterized by spongiform degeneration of the gray matter of the brain.

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

Providing palliative care Explanation: 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.

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 uses a mechanical lift to climb steps. 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 grasps the affected arm at the wrist and raises it. Explanation: The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "I will lose strength in my arms." "My children are at greater risk to develop this disease." "I need to remain active for as long as possible." "I will have progressive muscle weakness."

"My children are at greater risk to develop this disease." Explanation: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.

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. Explanation: Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.

An infusion of phenytoin (Dilantin) has been ordered for a patient whose brain tumor has just caused a seizure. The patient has been receiving D5W at 100 mL/hour to this point and has only one IV access site at this point. How should the nurse prepare to administer this drug to the patient? Thoroughly flush the patient's IV with normal saline. Administer the drug orally due to the risk of precipitation. Mix the phenytoin in a 50 mL mini-bag of D5W. Saline lock the patient's IV and wait 15 minutes before administering phenytoin.

Thoroughly flush the patient's IV with normal saline. Explanation: The rate of Dilantin administration is no faster than 50 mg/min in normal saline solution, since the drug precipitates in D5W. If the preexisting solution contained dextrose, the nurse flushes the IV line with normal saline before administering the medication.

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 has underlying aggression problems, which manifest in behavior." "The client may be experiencing a change in affect due to the brain injury." "All traumatic brain injury clients act in this similar way." "The client has demonstrated this behavior before and is now anticipated."

"The client may be experiencing a change in affect due to the brain injury." Explanation: It is not unusual for the family to identify a change in affect following a traumatic brain injury. This may include an alteration of lability of mood. Explaining this change to family is important in helping them understand the client's actions. Stating that the client has done this before and this is now anticipated does not provide the understanding and the support for the mother. There is no information provided to confirm past aggression problems. Not all traumatic brain injuries have a change in mood.

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? "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." "Don't worry; your child will be fine." "It's too early to give a prognosis."

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." Explanation: The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.

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? 2 hours prior to the administration of antibiotics for 7 days 1 hour after the antibiotic has infused and daily for 7 days 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 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 Explanation: 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

A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis? Imbalanced nutrition: less than body requirements Risk for deficient fluid volume Excess fluid volume Risk for unstable blood glucose

Excess fluid volume Explanation: A unique clinical feature of St. Louis encephalitis is the development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) with hyponatremia in 25% to 33% of affected patients; SIADH often results in profound fluid overload. Impaired nutrition and unstable blood glucose levels may occur.

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. Explanation: The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.

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

Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.

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 will stretch daily as directed by the physical therapist." "The exercises should be completed quickly to reduce fatigue." "I should participate in non-weight-bearing exercises."

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

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 Incentive spirometer Intubation tray and suction apparatus Nebulizer and thermometer

Intubation tray and suction apparatus Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan? Moving the neck from side to side when the collar is off Keeping the head in a neutral position Removing the entire collar when shaving Wearing the cervical collar when sleeping

Keeping the head in a neutral position Explanation: After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.

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 Trigeminal neuralgia Migraine headache Angina pectoris

Trigeminal neuralgia Explanation: Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

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? Call the rapid response team because the patient is preparing to arrest. Administer atropine to control the side effects of edrophonium. Administer diphenhydramine (Benadryl) for the allergic reaction. Place the patient in the supine position.

Administer atropine to control the side effects of edrophonium. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

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? Immune globulin is given intravenously. The thymus gland is removed. Mestinon therapy is initiated. Antibodies are removed from the plasma.

Antibodies are removed from the plasma. Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.

A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following? Bradykinesia Dysphonia Micrographia Dyskinesia

Dyskinesia Explanation: Most clients within 5 to 10 years of taking levodopa develop a response to the medication called dyskinesia, manifested as facial grimacing, rhythmic jerking movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities. Bradykinesia refers to an overall slowing of active movement and is a manifestation of the disorder. Micrographia refers to the development of small handwriting as dexterity declines with Parkinson's disease. Dysphonia refers to soft, slurred, low-pitched, and less audible speech that occurs as the disorder progresses.

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

Tensilon test Explanation: Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing? Turn the client to the side Administer mannitol Insert oral airway Place a cooling blanket on the client

Turn the client to the side Correct response: Turn the client to the side Explanation: When a client is seizing, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. An oral airway should not be inserted while the client is actively seizing. An oral airway may be inserted during the aura phase. Anticonvulsants may be administered, but mannitol is an osmotic diuretic, not an anticonvulsant. Applying a cooling blanket while the client is actively seizing could cause harm to the client and is not indicated for seizure activity.

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 Respiratory status Condition of skin Urinary output and capillary refill

Gag reflex and bowel sounds Explanation: Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nutrition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? Have the client lie on the back and lift the leg, keeping it straight. Ask if the client can walk. Ask if the client has had a bowel movement. Ask the client if there is pain on ambulation.

Have the client lie on the back and lift the leg, keeping it straight. Explanation: A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? Oral phenytoin IV phenobarbital IV lidocaine IV diazepam

IV diazepam Explanation: Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis? Imbalanced nutrition: Less than body requirements Risk for injury Ineffective airway clearance Impaired urinary elimination

Ineffective airway clearance Explanation: In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes the highest priority. Although Imbalanced nutrition: Less than body requirements, Impaired urinary elimination, and Risk for injury are also appropriate nursing diagnoses, they aren't immediately life-threatening.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period? A. Discourage the client from doing any range-of-motion (ROM) exercises. Have the client sit up in a chair as much as possible. Logroll the client from side to side. Elevate the head of the bed to 90 degrees.

Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of his hips and shoulders and eliminates twisting in his operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess? Muscle spasms Appetite Sleep pattern Mood and affect

Muscle spasms Explanation: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease? Clients generally do not adhere to the drug regimen. Drugs administered may not cause the requisite therapeutic effect. Clients take an assortment of different drugs. Drugs administered may cause a wide variety of adverse effects.

Drugs administered may cause a wide variety of adverse effects. Explanation: Drugs administered for Parkinsonism may cause a wide variety of adverse effects, which requires careful observation of the client. Over time, clients may respond less and less to their standard drug therapy and have more frequent "off episodes" of hypomobility. As a result, the nurse should administer the drugs closely to the schedule. Generally, a single drug called levodopa is administered to clients with Parkinson's disease. It is also not true that drugs may not cause the requisite therapeutic effect or such clients do not adhere to the drug regimen.

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? 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. Tell the patient to smile every 4 hours. Suggest applying cool compresses on the face several times a day to tighten the muscles.

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? Turning the client from side to side, using the logroll technique Keeping a pillow under the client's knees at all times Maintaining bed rest for 72 hours after the laminectomy Placing the client in semi-Fowler's position

Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse? Place the client in wrist restraints. Administer lorazepam per orders. Apply oxygen via nasal cannula. Reorient the client while gently holding their arms.

Reorient the client while gently holding their arms. Explanation: Some clients during the postictal phase will become confused and agitated. This reaction is not intentional, and most clients do not later remember becoming agitated. The nurse should attempt to calm and reorient the client, while also gently holding the arms to prevent the client from hitting, thereby preventing the client from doing injury to self or others. The nurse should always use restraints as a last resort; therefore, the nurse should try to reorient the client before applying wrist restraints. Lorazepam is not indicated for postictal agitation. It may be administered to prevent future seizures. Oxygen is not indicated for this client.

The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient? Limiting free water to 1 L per day Reorienting the patient to person, time, and place Using the incentive spirometer as prescribed Maintaining the patient on bed rest

Using the incentive spirometer as prescribed Explanation: Respiratory function can be maximized in GBS with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré does not affect cognitive function or level of consciousness. Fluid restriction is not indicated.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: 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. place an oral airway in the client's mouth to maintain an open airway. 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. Explanation: When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat non-elevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

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 Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.

A client is diagnosed with a brain abscess. Which medication will the nurse anticipate providing to the client? Select all that apply. Dexamethasone Hydrocodone Apixaban Metronidazole Lacosamide

Dexamethasone Metronidazole Lacosamide A brain abscess is a collection of infectious material within the tissue of the brain. Bacteria are the most common causative organisms. The most common predisposing conditions for abscesses among adults who are immunocompetent are otitis media and rhinosinusitis. Treatment is aimed at controlling increased intracranial pressure (ICP), draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection. It is important for antibiotics such as metronidazole to be started as soon as possible. Corticosteroids such as dexamethasone are used to reduce the cerebral edema caused by inflammation. Anticonvulsants such as lacosamide may be prescribed to prevent or treat seizures. Anticoagulants such as apixaban and opioid analgesics such as hydrocodone are not medications used to treat a brain abscess.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? Urine retention or incontinence More back pain than the first postoperative day Paresthesia in the dermatomes near the wounds Temperature of 99.2° F (37.3° C)

Urine retention or incontinence Explanation: Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. An increase in back pain is more common because on the second postoperative day the long-acting local anesthetic, which may have been injected during surgery, will wear off. Although paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. A mild fever is also common after surgery but is considered significant only if the temperature reaches 101° F (38.3° C).

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count EEG, blood cultures, and neuroimaging studies X-ray of the brain, bone marrow aspiration, and EEG Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR)

EEG, blood cultures, and neuroimaging studies Explanation: Physicians use EEG and neuroimaging studies to diagnose neurologic problems. Blood cultures can identify infection that can cause seizures. Electrocardiography, TEE, and troponin levels are cardiac-specific diagnostic tests. X-ray of the brain reveals skeletal condition. Bone marrow aspiration isn't indicated for seizure disorder. PT and INR reflect blood coagulation.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms are primarily associated with infection with Coccidioides immitis and Aspergillus. indicate renal toxicity and a worsening condition. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. 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. Explanation: 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. Renal toxicity due to amphotericin B is dose limiting. Monitoring serum creatinine and blood urea nitrogen levels may alert the nurse to the development of renal insufficiency and the need to address the clients' renal status. Vascular changes are associated with C. immitis and Aspergillus. Manifestations of vascular change may include arteritis or cerebral infarction. Blood and CSF cultures help diagnosis fungal encephalitis.

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 Explanation: 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 is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.

70 Explanation: 58 kg X 2 = 116 mcg/min. 116 mcg X 60 minutes = 6,960 mcg per hour. 6,960 mcg/1000 = 6.96 mg, rounded to 7 mg/hour. (7 mg/50 mg) X 500 mL = 70 mL/hour.

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs (65 kg). How many grams will the nurse administer to the client? Enter the correct number in tenths.

97.5 Explanation: 143 lbs/2.2 = 65 kg. 65 kg x 1.5 = 97.5 grams.

Which disease includes loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem? Parkinson disease Huntington disease Alzheimer disease Amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis Explanation: Amyotrophic lateral sclerosis (ALS) is a disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei of the lower brain stem. Parkinson disease is a slowly progressing neurologic movement disorder that eventually leads to disability. Alzheimer disease is a chronic, progressive, and degenerative brain disorder that is accompanied by profound effects on memory, cognition and ability for self-care. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time. Document the reading because it reflects that the treatment has been effective. Check the equipment.

Check the equipment. Explanation: A reading of 0 mm Hg indicates equipment malfunction. The nurse should check the equipment and report problems. Normal and stable ICP values are less than 15 mm Hg. Some pressure is always present in the cranial vault. The nurse shouldn't contact the physician to review the care plan at this time. The nurse needs to complete the assessment of the client and equipment before making a report to the physician.

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? Body rigidity Confusion Urinary incontinence Epileptic cry

Confusion Explanation: In the postictal state (after the seizure), the patient is often confused, hard to arouse, and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Elevate the head of the bed. Complete a head-to-toe assessment. Administer Percocet as ordered. Administer morning dose of anticonvulsant.

Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? Muscle spasms Shortness of breath Sensitivity to bright light Drooping eyelids

Drooping eyelids Explanation: Ptosis (eyelid drooping) is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis.

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

Ensure atropine is readily available. Explanation: 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.

A 55-year-old male patient has been admitted to the hospital with a gastrointestinal bleed, and the patient has just experienced a generalized seizure that may be attributable to alcohol withdrawal. When providing immediate care during the patient's seizure, what nursing diagnosis should be prioritized? Impaired gas exchange Risk for impaired skin integrity Acute pain Acute confusion

Impaired gas exchange Explanation: Airway and breathing are priorities in any emergency situation, including seizures. These considerations would be prioritized over confusion, pain, and skin integrity.

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? Increased ICP Increase in cerebral perfusion pressure Exacerbation of uncontrolled hypertension Infection

Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.

A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela? Cerebrovascular accident (CVA) Increased intracranial pressure (ICP) Glioma Hydrocephalus

Increased intracranial pressure (ICP) Explanation: Increased ICP is a significant risk in patients being treated for meningitis. This infection does not cause brain tumors, hydrocephalus, or CVA.

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

Magnetic resonance imaging Explanation: The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed with magnetic resonance imaging. 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 educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? Medications can be taken whenever convenient. Medications must be taken on time. There is no conflict with the disorder and dental work. Medications are best taken while the client is in a reclining position.

Medications must be taken on time. Explanation: If medications are not taken on time, exacerbations may occur, making it impossible for the client to take the medication orally. Medications must always be taken with the client upright to avoid aspiration. Procaine (Novocain) should be avoided and the client's dentist must be informed. Reference:

Which of the following is considered a central nervous system (CNS) disorder? Multiple sclerosis Guillain-Barré Myasthenia gravis Bell's palsy

Multiple sclerosis Explanation: Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation? Dantrium Neurontin Baclofen Valium

Neurontin Explanation: Ataxia is a chronic problem most resistant to treatment. Medications used to treat ataxia include beta-adrenergic blockers (Inderal), antiseizure agents (Neurontin), and benzodiazepines (Klonopin). Baclofen, Dantrium, and Valium are used in the treatment of spasticity.

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? Atrophy of the lower leg muscles Homans' sign Pain radiating down the posterior thigh Back pain when the knees are flexed

Pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? Pain radiating down the posterior thigh Atrophy of the lower leg muscles Homans' sign Back pain when the knees are flexed

Pain radiating down the posterior thigh Explanation: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

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

positive Kernig's sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Hyperactive patellar reflex and a sluggish pupil reaction are not common signs of meningitis. Reference:

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

supine position with the head slightly elevated. Explanation: After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.