Module 8 Patho

The nurse assesses a patient who presents with lower back pain, impaired touch sensation at L5-S1 levels, presence of babinski reflex, and mild weakness in the foot. Which instructions given by the nurse will help the patient manage pain?

"Refrain from repeated lifting." Impaired touch sensation at L5-S1 levels, presence of Babinski reflex, and mild foot weakness indicate that the patient has a herniated intervertebral disk (HID). The pain occurs with straining; therefore the nurse should instruct the patient to refrain from repeated lifting or lifting heavy objects to prevent further complications. Bed rest and nonsteroidal anti-inflammatory drugs have not been shown to improve associated sciatica, and most herniated disks will heal spontaneously over time. Raising the legs straight causes severe pain in the patient with HID, so the nurse will not instruct the patient to do stretching exercises.

A client has been admitted with a diagnosis of bacterial meningitis with a severely depressed level of consciousness. The spouse wants to know why this illness makes the client so sleepy and difficult to awaken. How should the nurse respond?

"The infection blocks the passages by which fluid is removed, thereby causing it to accumulate. This accumulation of fluid puts pressure on brain cells and prevents them from functioning normally." The inflammatory exudate thickens the cerebrospinal fluid (CSF) and interferes with normal CSF flow around the brain and spinal cord, possibly obstructing arachnoid villi and producing hydrocephalus. Meningeal cells become edematous, and the combined exudate and edematous cells increase intracranial pressure, which decreases the level of consciousness. Bacterial meningitis does not decrease the level of consciousness by pushing fluid out of brain cells nor by dilation of arachnoid villi, metaplasia, or increased production of CSF.

Which information should the nurse include when educating a client about bradykinesia?

"Walking will become slow and will take more time to start." Bradykinesia causes slowness of voluntary movements and includes slow gait, involving a delay in the time it takes to start to perform a movement. Bradykinesia does not result in loss of memory. Voluntary muscle movement is affected, not involuntary movements. Seizures and paralysis are not clinical manifestations of bradykinesia.

Which client has the lowest level of consciousness (LOC)?

A 28-year-old client who responds by withdrawing from a painful stimulus. The client with the lowest level of consciousness is the 28-year-old who is in a state of stupor. Next lowest LOC is the 36-year-old client and the 52-year-old client, who are both in a state of obtundation. The client with the highest LOC is the 49-year-old client who is a state of disorientation.

Which client is at highest risk for developing dementia and mental status changes?

A 74-year-old client who takes several medications to treat Parkinson disease Dementia in clients with Parkinson disease is more common in clients older than 70 years; mental status changes are also more common in clients who take medications. Spinal shock, upper motor neuron syndrome, and Guillain-Barré syndrome do not affect mental status.

Which clinical finding in a client will help a nurse distinguish between pyramidal motor syndromes and extrapyramidal motor syndromes?

A Babinski sign occurs with pyrmidal motor syndromes. A Babinski sign is present in pyramidal motor syndromes. Pyramidal motor syndromes will have paralysis. Extrapyramidal motor syndromes will have cogwheel rigidity with hypotonia. Absence of involuntary movement occurs in pyramidal motor syndromes.

A client diagnosed with cerebellar motor syndrome is likely to demonstrate which clinical finding upon assessment?

Difficulty standing on one foot Cerebellar motor syndromes are associated with ataxia and other symptoms affecting coordinated movement. Impaired respiration may be caused by brainstem injury. Problems with body temperature involve the hypothalamus. Hypermimesis commonly manifests as pathologic laughter or crying.

A client has cerebral death. Which findings will the nurse commonly observe upon assessment?

Does not speak Does not follow commands With cerebral death the person does not follow commands, speak, or have voluntary movement. Cerebral death is death of the cerebral hemispheres exclusive of the brainstem and cerebellum. The brainstem continues to maintain internal homeostasis (i.e., body temperature, cardiovascular functions, respirations, and metabolic functions). No spontaneous respiration occurs in brain death (when both cerebral death and brainstem death have occurred).

Which classical clinical manifesation will the nurse observe in a client diagnosed with Parkinson disease?

Dysarthria Dysphagia Bradykinesia The classic manifestations of Parkinson disease are resting tremor, rigidity, bradykinesia/akinesia, postural disturbance, dysarthria, and dysphagia. Clients with Parkinson disease do not develop true paralysis or flaccidity; urinary retention occurs, not incontinence.

A client has suspected Huntington disease. Which evaluation methods will be used to help determine the diagnosis?

Family history Clinical manifestations Huntington disease is diagnosed by family history, genetic testing, and clinical manifestations. Cranial nerve assessment and positron emission tomography would not be helpful to diagnose Huntington disease. A radioisotopic cisternogram may be performed to diagnose normal-pressure hydrocephalus.

A nurse is caring for a client with spinal cord injury. Which assessment findings will cause the nurse to conclude the client is in spinal shock?

Flaccid muscles Absence of sensation Loss of bladder control Transient drop in blood pressure Spinal shock [1] [2] involves all skeletal muscles; bladder, bowel, and sexual function; paralysis and flaccidity in muscles; absence of sensation; and transient drop in blood pressure. Spinal shock does not involve blurred vision; autonomic hyperreflexia does.

Which reflexes, if exhibited by the client, would indicate loss of cortical inhibition?

Grasp Sucking Palmomental Reflexes associated with loss of cortical inhibition include the grasp reflex, reflex sucking, and palmomental reflex. Gag and swallow reflexes are normal reflexes; these reflexes test function of cranial nerves IX and X. Corneal reflex is a normal reflex and tests function of cranial nerves V and VII.

While assessing a patient, the nurse finds that the patient has paresis of the legs, paralysis of the eyes muscles, and respiratory insufficiency. The laboratory reports indicate that the patient has respiratory viral infection. What condition should the nurse anticipate to find in the patient?

Guillian-Barre syndrome Paresis of the legs, paralysis of the eye muscles, and respiratory insufficiency indicate that the patient more than likely has Guillain-Barré syndrome. Guillain-Barré syndrome is usually caused by autoimmune inflammatory response or a viral respiratory infection. Neuropathies are characterized by paralysis of the foot muscles, legs, and arms, but not the eyes. Plexus injuries are associated with motor weakness, muscle atrophy, and sensory loss. Radiculopathies are associated with the absence of deep tendon reflexes from injury to spinal roots as they exit or enter the vertebral canal.

Which information should the nurse include when discussing attention deficit hyperactivity disorder (ADHD)?

It is a common childhood disorder. Impulsivity is often a characteristic. Inability to maintain sustained attention is common. Working memory, the ability to remember instructions and information needed to guide behavior, is affected by ADHD, and impulsivity is often a characteristic. ADHD is a common childhood disorder. It typically begins in childhood, and for 50% to 75% of those diagnosed, it continues throughout adolescence and adulthood. ADHD causes an inability to maintain sustained attention.

While assessing a patient with a vertebral injury, the nurse finds that the patient has experienced a loss of sensation and reflexes, as well as hypotension. Which other clinical manifestation should the nurse anticipate finding in the patient?

Poikilothermia Urinary incontinence Flaccidity in the muscles Hypotension and loss of sensation and reflexes indicate that the patient has spinal shock. Spinal shock impairs thermoregulation due to which the patient has poikilothermia. Due to loss of reflexes, the patient with spinal shock has impaired bladder control and involuntary urination resulting in urinary incontinence. Spinal shock causes flaccidity in the muscles and increases the risk of paralysis. Spinal shock does not cause protrusion of the rectal wall, nor result in rectal prolapse. Spinal shock does not increase the number of hepatocytes; therefore the patient is not at risk of liver enlargement.

A nurse is assessing a patient with a peripheral nervous system disorder. The computed tomography scan shows injury to spinal roots caused by compression, inflammation, and direct trauma. Which disorder does the nurse expect to find in the chart?

Radiculopathy Radiculopathy is a peripheral nervous system disorder that affects strength, tone, and bulk of the muscles innervated by the involved roots. Radiculopathy occurs due to injury to the spinal roots caused by compression, inflammation, and direct trauma. Therefore the nurse will expect that the patient has radiculopathy. Neuropathy is a peripheral nervous system disorder caused by hereditary mechanisms, leprosy, or industrial solvents. While trauma and compression can cause plexus injuries, it involves the nerve plexus distal to spinal roots. Guillain-Barré syndrome is caused by an autoimmune inflammatory response causing axonal demyelination. Therefore the nurse does not expect Guillain-Barré syndrome in this patient.

Which assessment finding leads the nruse to conclude that the client is experiencing early increased intracranial pressure?

Restlessness The client may have episodes of confusion, restlessness, drowsiness, and slight pupillary and breathing changes during early increased intracranial pressure. Unresponsiveness, inability to move, and inability to verbalize are signs that occur later.

What is a clinical manifestation of a right-sided cerebellar astrocytoma in a child?

Right head tilt A right sided cerebellar astrocytoma will cause right-sided symptoms. Cerebellar astrocytomas are located on the surface of the right or left cerebellar hemisphere and cause unilateral symptoms (occurring on the same side as the tumor), such as head tilt, limb ataxia, and nystagmus. Hydrocephalus occurs in ependymoma. Positive Brudzinski sign occurs in meningitis.

When assessing intentional tremors, what will the nurse observe when a client has myoclonus?

Spasm of a muscle Myoclonus is defined as a nonpatterned contractions of portions of a muscle in which there is throwing movements of a limb. Hypomimesis occurs when there is an inability to express emotions in facial expressions. Asterixis is an irregular flapping movement of the hands. Dyspraxia is uncoordinated motor movements.

After assessing a patient with herniated intervertebral disk (HID), the nurse suspects that the primary health care provider will recommend surgery for the patient. Which findings support the nurse's conclusion?

The patient has weak bowel reflexes. The pateint has weak deep tendon reflexes. Weak bowel and deep tendon reflexes indicate that the patient has severe nerve damage. Therefore surgery may be necessary to repair the herniated disk. A strong bladder reflex indicates that the patient is normal and does not have risk of bladder distention. A patient with HID will have Babinski reflexes due to sensory impairment. Weak Babinski reflexes indicate that the patient is improving and does not require surgery. Presence of strong ankle jerk reflexes indicates that the patient does not have motor weakness in the lower limbs.

A client was found at home in the fetal position reporting a severe, sudden onset headache. Assessments in the emergency department reveal confusion, disorientation, and one dilated pupil. While waiting for the primary healthcare provider, respiration have now changed to a cyclic rhythm from increasing depth and rate to periods of apnea. Hiccups have begun. What is the nurse's best response to family concerns?

These changes are significant. I will have the healthcare provider evaluate these changes immediately. The nurse needs to notify the primary healthcare provider immediately. Vomiting, yawning, and hiccups are complex reflex-like motor responses that are integrated by neural mechanisms in the lower brain. These responses may be produced by compression or diseases involving tissues of the medulla oblongata. Hiccups and Cheyne-Stokes respirations are significant changes, indicating possible increased intracranial pressure. An emergency situation like the client is experiencing will be performed before scheduled CT scans. Hiccups indicate the client is deteriorating and there should be concern.

A nurse is caring for a client with meningitis. Which information indicates a nurse has an accurate understanding about meningitis?

Viral meningitis generally has milder symptoms than bacterial meningitis. Aseptic (viral or nonpurulent meningitis) has similar symptoms to bacterial meningitis, but milder. Fungal meningitis is uncommon. Aseptic meningitis is most commonly caused by a virus. Bacterial meningitis is caused by primary infection of the pia mater and arachnoid.

Which clinical manifestation is one finding that would indicate the presence of brain death in a client who has sustained a serious brain injury?

Apnea Criteria for brain death include apnea, no brainstem function, and a flat electroencephalography (EEG). Decerebrate rigidity, gag reflex, and snout reflex indicate the presence of brainstem function.

A 6-year-old child loses consciousness for 7 seconds with no convulsive activity expect for twitching of the eyelids. Which type of seizure has occurred?

Absence An absence seizure is diagnosed if there is a brief loss of consciousness (5 to 10 seconds) with minimal or no loss of muscle tone, and there may be minimal motor movement such as eyelid twitching. The myoclonic and tonic-clonic seizures will manifest with convulsions. A simple seizure is a partial-type seizure that is limited to one part of the left or right hemisphere and has seizure activity without loss of consciousness.

An individual having difficulty concentrating is restless, irritable, and tremulous. These changes have developed over 2 to 3 days. Which term will the nurse use to describe this condition?

Acute confusional state The onset of an acute confusional state usually is abrupt. The first clinical manifestations are difficulty in concentration, restlessness, irritability, tremulousness, insomnia, and poor appetite. Coma is a loss of consciousness and unresponsiveness to stimuli. Dementia is a more chronic problem during which progressive failure of many cerebral functions occurs. Hemiparesis is paresis of the upper and lower extremities on one side.

An adult client presents with weakness of the facial muscles, impaired articulation of r, n, l, and raspy voice. On physical examination, the pharyngeal reflexes are diminished. Which diagnosis is supported by the assessment data?

Bulbar palsy Clinical manifestations of bulbar palsy include paresis or paralysis of the jaw, face, pharynx, and tongue musculature, impaired articulation of r, n, l, and raspy voice with diminished pharyngeal reflexes. Clinical manifestations of tardive dyskinesia include involuntary muscle movements. Clinical manifestations of Tourette syndrome include multiple motor and vocal tics. Locked-in syndrome involves complete paralysis of voluntary muscles except for eye movement.

A client presents with a wide-base gait, in which the feet are turned outward. Upon assessment, the client staggers when walking and holds the pelvis stiff. Which condition do these assessment findings support?

Cerebellar gait A cerebellar gait is wide based with the feet apart and often turned outward or inward for greater stability. The pelvis is held stiff, and the individual staggers when walking. Apraxia is the inability to perform purposeful or skilled motor acts. Basal ganglion gait is a wide-based gait in which the person walks with small steps and decreased arm swing. Decorticate posture occurs when the upper extremities are flexed at the elbows and held close to the body while the lower extremities are externally rotated and extended.

A client has a central nervous system injury that is causing vomiting. Which information should the nurse remember when planning care about what can cause vomiting?

Compression of the medulla oblongata Impingement directly on the floor of the fourth ventricle Vomiting that is associated with central nervous system injuries involves the vestibular nuclei or their immediate projections or compression of the medulla oblongata. Vomiting can be caused by an impingement on the fourth ventricle, not on the third ventricle. It can also be the result of brainstem compression from an increase in intracranial pressure.

Which information indicates the nurse has a correct understanding of the causes for the development of sensory and motor symptoms in clients with multiple sclerosis?

Immunologic demyelination of axons in the central nervous system Multiple sclerosis is an autoimmune disease that causes axonal demyelination of central nervous system (brain and spinal cord) neurons. Increased glutamate, not GABA, is associated with multiple sclerosis. Myasthenia gravis results from a defect in nerve impulse transmission at the neuromuscular junction. Multiple sclerosis affects the central nervous system, not the peripheral nervous system.

The registered nurse instructs a student nurse to draft a care plan for a patient with a vertebral fracture who has developed symptoms of spinal shock. Which is the priority intervention in the care plan?

Maintain a patent airway. A patient with spinal shock [1] [2] has muscle flaccidity, which impairs the functioning of phrenic muscles and causes respiratory impairment. Therefore the priority is to maintain a patent airway, which helps to prevent hypoxia. Due to loss of bladder control, the patient with spinal shock is at risk of urinary incontinence and fluid and electrolyte imbalances; however, maintaining electrolyte balance is not prioritized over maintaining a patent airway. Spinal shock does not cause hyperglycemia, so the nurse would not need to monitor the patient's blood glucose levels. A patient with spinal shock has poikilothermia due to impaired thermoregulation, so the nurse should adjust the room temperature as needed to prevent hypothermia and hyperthermia; however, this intervention is not prioritized over maintaining a patent airway.