Med Surg chapter 49 & 50

The nurse is visiting the home of a patient who is being treated for Bell palsy. Which statement by the patient indicates that care instructions need to be reviewed by the nurse?

"Alternating heat and cold therapy is helping the swelling."

A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?

1230 hours

The nurse is providing care for a patient after surgery for treatment of trigeminal neuropathy. Which nursing intervention will the nurse initiate for this patient?

Check the eye on the surgery side for corneal sensation.

The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate?

Check the patient's mouth periodically for presence of pocketed food.

The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change does the nurse recognize as causing the manifestations of MS?

Demyelination and destruction of nerve fibers

The nurse is assisting with care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency?

Indications of the development of pneumonia

The nurse is collecting data from a patient who is diagnosed with MG. Which data is most important for the nurse to obtain?

Monitor the patient's respiratory function and the ability to swallow effectively.

The nurse is providing care for a patient diagnosed with a cerebral aneurysm and subarachnoid hemorrhage. Which statement by the patient indicates a need for additional information?

No strenuous activity until this condition is cured by surgery."

The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patient's current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated?

Permissive hypertension is being therapeutically used to salvage brain tissue.

A patient reports to the nurse an inability to rest or sleep due to a long-term condition causing a constant urge to move the legs called restless legs syndrome (RLS). The patient expresses a need for some type of relief. Which suggestion by the nurse is most likely to help the patient?

Pramipexole or ropinirole medication therapy

A patient is recovering from a stroke. The family reports to the nurse that the patient alternates between periods of crying for no given reason to periods of laughing inappropriately. Which condition does the nurse suspect the patient is exhibiting?

Pseudobulbar effect (patient yells out random things)

The nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue?

Receptive Aphasia

A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider (HCP) is unexpected by the nurse?

Scheduling laboratory tests, electrocardiogram (ECG), and computerized tomography (CT) scan to be performed within 45 minutes

The nurse is providing care for a patient recovering from a right hemisphere infarct who now exhibits unilateral neglect. Which nursing intervention is most important at promoting safety for this patient?

Teach the patient to purposefully check the location of the left limbs.

The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation?

The ability to participate in intensive therapy

The nurse is assisting with the care of a patient diagnosed with post polio syndrome. The nurse asks the registered nurse (RN) to explain the source of the disease. Which answer by the RN is correct?

The patient must first have had a poliovirus infection.

A patient comes into the emergency department with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke?

Tissue-type plasminogen activator (tPA)

The nurse is providing care for a patient diagnosed with an ischemic stroke on the left side of the brain. The nurse notices that the patient does not easily locate items placed at the bedside. In which area does the nurse place items for easy location?

right side

A patient is scheduled for a thymectomy. For which peripheral nervous system disorder does the nurse plan care for this patient?

MG

The nurse is collecting up-to-date data from a patient who was diagnosed with MS 15 years ago. The patient has a good understanding of the disease and manages to maintain a relatively high level of functioning. Which statement by the patient prompts the nurse to seek additional information?

"I love to work in my flower beds during the summer months."

A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. Which nursing response is the most accurate?

"It may be an autoimmune reaction to a virus."

A mother of three young children has a 3-year history of MG and recently stopped helping in the children's classrooms because of fatigue. Which advice does the nurse give to help the patient best cope with the problem?

"Time your medication so its action peaks during the time you need the most energy."

The nurse reviews information with a patient and family members about the patient's recent diagnosis of amyotrophic lateral sclerosis (ALS). Which comment by a family member indicates a need for clarification?

"When the heart muscle is affected, death will occur shortly."

The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke?

Contact sport trauma

The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke?

An older female patient who has osteoporosis, a femur fracture, and hyperlipidemia

A patient arrives at the emergency department and states, "Something is wrong. I just don't feel right." Which objective data causes the nurse to suspect the patient is experiencing some type of stroke?

Ataxia is present when the patient attempts to ambulate

The nurse is preparing a patient with MG to undergo plasmapheresis. Which laboratory tests does the nurse verify and place on the medical record before the procedure?

Complete blood count, platelets, and clotting studies

A patient is admitted from the emergency department to the hospital unit following the diagnosis of an ischemic stroke. The patient did not qualify for tPA therapy. The nurse is aware that which poststroke condition places the patient at greatest risk for deep vein thrombosis (DVT)?

Hyper-coagulability related to the admitting diagnosis

A patient who is prescribed neostigmine for newly diagnosed MG asks how the medication works. Which response does the nurse provide to the patient?

It makes more neurotransmitters available so that your muscles can contract."

The nurse is assisting the registered nurse (RN) in providing care for a patient who is recovering from a stroke. Which assigned intervention by the RN will the nurse question?

Observe the patient performing active range of motion (ROM) on the affected side.

A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. Which intervention is appropriate for this patient?

Provide soft foods at body temperature at mealtimes.

A patient in the plateau stage of GBS is frustrated because there has been no improvement in manifestations for 5 days. Which explanation does the nurse provide to the patient?

The manifestations can last up to 2 weeks.

The nurse is providing care for a patient being treated for trigeminal neuropathy. The nurse is concerned about the patient's nutritional status because of an inability to eat without experiencing severe pain. Which patient behavior indicates the nurse's interventions are successful?

The patient can eat multiple small, soft, lukewarm meals daily.

A patient arrives in the emergency department at 0200 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to a blood clot, for which reason is tPA therapy withheld?

The therapy is based on the time the patient went to bed.

The nurse is collecting information from a patient in the HCP's office. The patient is exhibiting symptoms associated with Bell palsy. Which population group does the nurse recognize as being at greatest risk for the condition?

Women in the third trimester of pregnancy

The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and the highest probability of causing extensive neurologic deficits. For which type of stroke does the nurse plan care for this patient?

subarachnoid hemorrhage (SAH)