Neuro Prep U Leukhardt
The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? Assessing frequently for loss of cognitive function Providing aids to compensate for loss of vision Using the incentive spirometer as prescribed Maintaining the client on bed rest
Using the incentive spirometer as prescribed Explanation: Respiratory function can be maximized 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 syndrome does not affect cognitive function or vision.
Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Spasticity Pain Numbness Aphasia Fatigue Depression
Pain Fatigue Spasticity Depression Numbness Explanation: The most commonly reported clinical manifestations of MS are pain, fatigue, spasticity, depression, numbness, weakness, difficulty with coordination, and loss of balance. Aphasia is not a commonly reported clinical manifestation.
Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply. Systolic BP less than or equal to 185 mm Hg Age 18 years or older intracranial hemorrhage Ischemic stroke Major abdominal surgery within 10 days
intracranial hemorrhage Major abdominal surgery within 10 days Explanation Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for signs of improvement in the patient's condition. renal complications related to acyclovir therapy. signs of relapse. signs and symptoms of cardiac insufficiency.
renal complications related to acyclovir therapy. Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.
A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply. seizure activity increasing ICP respiratory distress difficulty swallowing
respiratory distress difficulty swallowing Explanation: Respiratory muscles may become paralyzed, requiring endotracheal intubation and mechanical ventilation. If cranial nerve involvement develops, swallowing becomes difficult. Increasing ICP and seizure activity are not expected complications of Guillain-Barré syndrome.
The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process." "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."
"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." 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 cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the client's concerns by wholly deferring to the health care provider.
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. Decreased glucose Increased protein Increased glucose Increased white blood cells Decreased protein
Decreased glucose Increased protein Increased white blood cells Explanation: CSF studies demonstrate decreased glucose, increased protein levels, and increased white blood cells.
A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take? Use one long sentence to say everything that needs to be said. Face the client and establish eye contact. Talk in a louder than normal voice. Keep the television on while she speaks.
Face the client and establish eye contact. Explanation: When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client's diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Instruct the client to lie on the bed when eating Allow optimum physical activity before meals to expedite digestion Help the client sit upright when eating and feed slowly Offer liquids frequently, in large quantities
Help the client sit upright when eating and feed slowly Explanation: A client who has impaired swallowing should be helped to eat foods with texture. The nurse should help such a client sit upright, flex the client's chin toward the chest, and feed slowly. These measures promote easy swallowing of food and reduce the risk of aspiration or airway obstruction. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions. Liquids should be offered frequently but in small quantities.
While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? Impaired physical mobility Ineffective role performance Disturbed sensory perception: Kinesthetic Ineffective health maintenance
Impaired physical mobility Explanation: Impaired physical mobility is a limitation of physical movement that is identified by the characteristics found in this client. The other listed diagnoses are not directly suggested by the noted assessment findings.
A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications? Placement of a colostomy tube Placement of a tracheostomy tube Placement of a urinary catheter Placement of a feeding tube
Placement of a feeding tube Explanation: Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube may need to be placed if the deficit is prolonged and if the client is unable to eat. Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube would be placed to address this deficit.
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Renal Musculoskeletal Integumentary Hepatic
Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.
The primary arthropod vector in North America that transmits encephalitis is the mosquito. flea. tick. horse.
mosquito. Explanation: Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.
A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. Encourage the client to increase his/her intake of water and juice. Instruct the client to tuck his/her chin towards their chest when swallowing. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. Assist the client out of bed and into the chair for meals. Request a swallowing assessment by a speech therapist before the client's discharge.
Assist the client out of bed and into the chair for meals. Instruct the client to tuck his/her chin towards their chest when swallowing. Explanation: If swallowing function is partially impaired, it may return over time, or the client may be educated in alternative swallowing techniques, advised to take smaller boluses of food, and educated about types of foods that are easier to swallow. The client may be started on a thick liquid or pureed diet, because these foods are easier to swallow than thin liquids. Having the client sit upright, preferably out of bed in a chair, and instructing them to tuck the chin toward the chest as they swallow will help prevent aspiration. Recommending the insertion of a percutaneous endoscopic gastrostomy (PEG) tube would not prevent the client from aspirating while eating. A PEG tube could be placed if the client was unable to tolerate or resume an oral intake. A swallowing assessment should be done before allowing any oral intake and preferably within 4 to 24 hours after a stroke. A nurse can also accomplish a swallowing study using a validated and reliable assessment tool.
The nurse is assessing a male client with multiple sclerosis (MS). What education would the nurse provide to assist the client in managing this disease? Select all that apply. Recommend bone mineral density testing Treatment of any episodes of depression Effective treatment of anemia Participation in occupational therapy Avoidance of hot temperatures
Avoidance of hot temperatures Treatment of any episodes of depression Effective treatment of anemia Participation in occupational therapy Explanation: Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the central nervous system (CNS). Fatigue affects most people with MS and is often the most disabling symptom. Heat, depression, anemia, deconditioning, and medication may contribute to fatigue. Avoiding high temperatures, effective treatment of depression and anemia, a change in medication, as well as occupational and physical therapy may help manage fatigue. Pain is another common symptom of MS. Bone mineral testing is recommended for women with MS who are perimenopausal. This group of clients are likely to have pain related to osteoporosis.
A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? Assess lung sounds. Explain the progression of the syndrome. Call the physician and prepare for intubation. Encourage the client to cough.
Call the physician and prepare for intubation. Explanation: The progression of Guillain-Barré syndrome leads to neuromuscular respiratory failure in a large proportion of the people affected. Changes in vital capacity and negative inspiratory force are usually key indicators to be monitored for early intervention. The nurse should be alert to the earliest signs that a client may be heading toward respiratory failure. Explaining the progression of the syndrome will not change the potential need for mechanical ventilation due to respiratory failure. Because the respiratory failure is caused by neurologic changes, assessing the lung sounds, although appropriate, is not the highest priority . Encouraging the client to cough will not change the progression of the syndrome.
The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply. Speak in a normal tone of voice Pause between phrases Use gestures when talking Talk over the television volume Face the client when talking
Pause between phrases Use gestures when talking Face the client when talking Speak in a normal tone of voice Explanation: Communicating with a client with aphasia can be challenging. Actions to improve communication include pausing between phrases, using gestures when talking, facing the client when talking, and speaking in a normal tone of voice. Extraneous background noise should be kept to a minimum. Turning off the sound on the television would be beneficial to improve communication.
A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? Temporal lobe Cerebral cortex Penumbra region Central sulcus
Penumbra region Explanation: In an ischemic stroke, there is disruption of the cerebral blood flow due to obstruction of a blood vessel. This disruption in blood flow initiates a complex series of cellular metabolic events referred to as the ischemic cascade. Early in the cascade, an area of low cerebral blood flow, referred to as the penumbra region, exists around the area of infarction. The penumbra region is ischemic brain tissue that may be salvaged with timely intervention. The cerebral cortex, temporal lobe, and central sulcus are all different areas of the brain. Since the specific area was not identified in the scenario; the area that would most benefit from immediate interventions would be the area surrounding the infarct called the penumbra region.
The nurse is caring for a client recovering from a stroke. Which action will the nurse take to prevent adduction of the client's affected shoulder? Select all that apply. Position the arm parallel to the torso. Situate the arm in a slightly flexed position. Place a pillow in the axilla area. Put a rolled towel in the affected hand. Position the wrist higher than the elbow.
Place a pillow in the axilla area. Position the wrist higher than the elbow. Explanation: To prevent adduction of the affected shoulder, a pillow is placed in the axilla when there is limited external rotation. Doing so keeps the arm away from the chest. A pillow is placed under the arm, and the arm is placed in a slightly flexed position. Distal joints are to be positioned higher than the more proximal joints, or the wrist positioned higher than the elbow. This helps to prevent edema and the resultant joint fibrosis that will limit range of motion when the client regains control of the arm. A hand roll is not used because it stimulates the grasp reflex. Postioning the arm parallel to the torso could increase edema.
A client is diagnosed with an ischemic stroke. For which reason(s) would the nurse question the use of tissue plasminogen activator (tPA) for this client? Select all that apply. Platelet count 95,000/mm3 Diastolic blood pressure 120 mm Hg Received low-molecular weight heparin injections twice a day Systolic blood pressure 198 mm Hg Prothrombin time 10 seconds
Platelet count 95,000/mm3 Systolic blood pressure 198 mm Hg Diastolic blood pressure 120 mm Hg Received low-molecular weight heparin injections twice a day Explanation: There are specific criteria for the administration of tissue plasminogen activator (tPA). The administration of this medication is to be questioned if the platelet count is less than 100,000/mm3. The systolic blood pressure has to be less than or equal to 185 mm Hg. The diastolic blood pressure has to be less than or equal to 110 mm Hg. Lastly, the client is not to have received low-molecular weight heparin during the past 24 hours. The prothrombin time needs to be less than or equal to 15 seconds for eligibility.
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do? Anticipate the client will exhibit some degree of expressive or receptive aphasia. Provide close supervision because of the client's impulsiveness and poor judgment. Support the right arm with a sling or pillow to prevent subluxation. Place the wheelchair on the client's left side when transferring him into a wheelchair.
Provide close supervision because of the client's impulsiveness and poor judgment. Explanation: The primary symptoms of a client who experiences a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment. Aphasia is more commonly present when the dominant or left hemisphere is damaged. When a client has one-sided weakness, the nurse should place the wheelchair on the client's unaffected side. Because a right-sided stroke causes left-sided paralysis, the right side of the body should remain unaffected.
