Nursing Care: Altered Intracranial Regulation

Medication Teaching: Stroke Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity What medication would the nurse anticipate providing education to Janet about adding to her daily regimen after discharge?​ warfarin omeprazole Low dose aspirin Tissue plasminogen activator (tPA)​

Adding a daily antiplatelet medication, like low dose aspirin, will help decrease the risk of another transient ischemic attack (TIA) because clots will not form as readily. Tissue plasminogen activator (tPA) is a fibrinolytic and is not appropriate for daily maintenance. Omeprazole is a proton pump inhibitor that is used for symptom management of gastroesophageal reflux disease (GERD). Janet is likely already on warfarin because of her atrial fibrillation, and this medication would not be prescribed for a TIA.

Classifications of Spinal Cord Injuries What are the components to the classification of spinal cord injuries (SCI)? Select all that apply. Level of injury​ Time of injury Age of injury Degree of injury Mechanism of injury

When assessing and classifying spinal cord injuries (SCI), there are three components to be evaluated. The level of the injury, mechanism of injury, and the degree of injury are the concepts in classification of SCI.

Taking Action What is the purpose of the therapeutic care environment for a client living with cognitive impairment? Help the client become popular in a controlled setting Assist the client to relate to others Maintain the highest level of safe and independent functioning Make the hospital atmosphere more homelike

When working with clients living with cognitive impairment, the therapeutic milieu is directed toward helping them develop effective ways of functioning safely and independently. While a therapeutic care environment may help the client relate to others and feel comfortable, it is not intended to create a homelike atmosphere or help the client become popular. For clients living in a residential care facility, the atmosphere is purposefully structured to be more homelike, and family are encouraged to bring in furniture and other belongings familiar to the client since that is now their permanent home.

Interprofessional Care: Spinal Cord Injury When a client suffers a spinal cord injury (SCI), the priority becomes maintaining a patent airway, ventilation/breathing efforts, and adequate circulation (ABCs) while also preventing further injury (secondary injury). A rigid, cervical collar should be applied to any client who is suspected to have suffered an SCI to prevent further damage to the spinal cord. Spinal immobilization requires more team members to assist in the movement of the client as any transfers/movements should be completed in the logrolling technique. ​ Early surgical intervention (within the first 24 hours of the injury) to help decompress the spinal cord and manage any instability may reduce secondary injury threats and improve client outcomes. The type of surgery performed depends on the classification of the injury—including the level, mechanism, and degree of injury. ​ Nonoperative therapy options involve stabilizing the injured spinal segment and decompression through other means, including traction or realignment. Medications can also be used to decrease the issues that arise with SCI, such as deep vein thrombosis (DVT). ​

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Introduction to Dementia Cognitive impairment such as dementia impacts all facets of life, for both the client and the caregiver. These disease processes impact functional ability and the client's ability to work, complete activities of daily living (ADLs), and fulfill responsibilities in life. There is a high risk for many problems that occur to the client with dementia, including injuries, impaired nutrition, and social isolation. It is incredibly important for the nurse to identify potential problems or challenges with these clients, and educate both the client and the caregiver on how to handle this progressive disease. ​By completing these learning activities, the learner will gain the knowledge and skills needed to:​ Model Chamberlain Care when communicating with clients, families, and other healthcare providers.​ Assess a patient for dementia.​ Identify nursing diagnoses for clients who have dementia.​ Develop and implement a plan of care to address and intervene in clients with dementia.​ Evaluate a plan of care to determine the effectiveness and to strategize changes that may be needed based on the nursing assessment of clients with dement

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Introduction to Parkinson's Disease Parkinson's disease (PD) is a chronic, neurodegenerative disorder that impacts nearly all facets of a client's life. Affecting and destroying specific neurons, PD causes issues both with movement and sensory function. While there is no cure for PD currently, medical treatment with pharmacology and surgical interventions can assist a client to maintain independence and autonomy in their care for longer periods of time. This concept focuses on the nursing application of Parkinson's disease. ​By completing these learning activities, the learner will gain the knowledge and skills needed to:​ Model Chamberlain Care when communicating with clients, families, and other healthcare providers.​ Assess a client for Parkinson's disease.​ Identify nursing diagnoses for clients who have Parkinson's disease.​ Develop and implement a plan of care to address and intervene in clients with Parkinson's disease.​ Evaluate a plan of care to determine the effectiveness and to strategize changes that may be needed based on nursing assessment of clients with Parkinson's disease.​

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Parkinson's

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Introduction to Nursing Care: Spinal Cord Injuries According to National Spinal Cord Injury Statistical Center's 'Facts and Figures at a Glance 2020', there are approximately 294,000 Americans currently living with spinal cord injuries (SCI) and 17,810 new cases each year. About 78% of new SCI cases are male" (United Spinal Association, 2020). SCI are complex injuries that impact not only physical and motor function, but also the psychosocial function of the client and their loved ones. Compassionate, holistic, and realistic nursing care is the cornerstone for a significant impact on a spinal cord injury client's overall well-being and longevity of health. This concept focuses on the nursing application of spinal cord injuries. By completing these learning activities, the learner will gain the knowledge and skills needed to:​ Model Chamberlain Care when communicating with clients, families, and other healthcare providers Assess a client for spinal cord injuries Identify nursing diagnoses for clients who have spinal cord injuries Develop and implement a plan of care to address and intervene in clients with spinal cord injuries Evaluate a plan of care to determine the effectiveness and to strategize changes that may be needed based on nursing assessment of clients with spinal cord injuries

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Evaluating Outcomes The nurse is caring for a client suffering from altered cognition and memory impairment. The client has a nursing diagnosis of risk for injury. How does the nurse know that the client teaching and outcomes have been effective? The client understands that their physical and occupational therapy are scheduled for post discharge. The client verbalized an understanding that they have memory impairment issues. The client says that they will maintain adequate hydration and nutritional status. The client states that they will remove all area rugs in living areas at home and wear closed toed shoes.

A client with a nursing diagnosis of risk for injury will show effective teaching by indicating their understanding of how to reduce this risk. Moving all area rugs from walkways, wearing closed toed shoes while walking, picking up loose or stray cords on the floor, and having well lit areas are all good ways to reduce the risk of being injured.

Priority Assessment ​ The nurse receives report on the following four clients. Which client does the nurse assess first?​ A 28-year-old client with Huntington's disease waiting for discharge instructions. A 42-year-old client with myasthenia gravis experiencing difficulty swallowing​. A 63-year-old postictal client needing their scheduled dose of phenytoin​. A 50-year-old client with multiple sclerosis who needs to receive plasmapheresis treatment.

A client with myasthenia gravis (MG) who is having trouble swallowing is at risk for aspiration and airway compromise. They are the priority assessment.

Approach to Nursing Care: Dementia​ In what ways can a consistent care approach, provided by the healthcare team, benefit clients with dementia? Select all that apply. Increases client's orientation to reality Helps clients learn that the staff can be manipulated Provides consistency in their environment Allows clients to relate to staff in a consistent manner Assures acceptance of controls that are concrete and fairly applied

A consistent approach and communication from all members of the health team will help the client who has dementia to remain a bit more reality-oriented, allow them to relate to the consistent staff members, and establish a routine for themselves.​ The healthcare team approach is not intended to demonstrate to clients that the clients can manipulate the staff.

Mean Arterial Pressure Calculation​ What impact does a mean arterial pressure have on intracranial regulation? A high mean arterial pressure may indicate a high intracranial pressure in a susceptible client. A low mean arterial pressure could suggest that there is altered intracranial regulation. A high mean arterial pressure means that there is great cerebral perfusion. A high mean arterial pressure indicates that the intracranial pressure is low.

A high mean arterial pressure may indicate a high intracranial pressure in someone who has a condition with altered intracranial regulation. While a high mean arterial pressure means there may be more cerebral blood flow, perfusion may in fact be less due to the pressure in the brain exerting resistance. A low mean arterial pressure may indicate a lot cerebral perfusion pressure, but does not suggest altered regulation. When the mean arterial pressure is high, the cerebral perfusion pressure is high.

Focusing Care: Lorena Click on the "Nurse Notes" tab and view the assessment information. Based on assessment information, which complication of Alzheimer's disease should the nurse identify that Lorena is experiencing? Patient Information Nurses' Notes Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Is this just my mom aging? I don't know how to help her". Delirium Malnutrition Sundowning Cognitive decline

A specific type of agitation is sundowning. It is when the client becomes more confused and agitated in the late afternoon or evening. This may be due to the disruption in the circadian rhythm, but the cause of sundowning is unclear. Focusing care for clients with sundowning include: Remain calm and avoid confrontation with a sundowning client Try to provide a quiet, calm environment for the client Reducing caffeine intake (and naps) Evaluate any medications the client may be on that could be affecting their sleep patterns

Upon admission, the client who has head injury has the following baseline vital signs; blood pressure 126/70 mm Hg, heart rate of 110 beats per minute and respiratory rate of 25 breaths per minute. Which set of vital signs, if taken an hour later will be the most concerning to the nurse?

A widening pulse pressure, bradycardia, and irregular respirations are all signs of Cushing's Triad, an indication of severely increased intracranial pressure and possible brain stem herniation. The other vital signs, while concerning, may not indicate the need for immediate action.

Huntington's Disease Huntington's disease (HD) is a genetic, progressive neurodegenerative brain disorder. The child of a person with HD has a 50% chance of inheriting this autosomal dominant disorder. Unfortunately, there is no cure for HD, and the death occurs within 10 to 30 years after the onset of symptoms. The most common cause of death is pneumonia, followed by suicide.

About Huntington's Disease Huntington's disease (HD) is linked to an excess of dopamine and a deficiency of acetylcholine. This causes symptoms that are the opposite of Parkinson's disease. Clinical Manifestations​ Abnormal and excessive involuntary movements (chorea) ​Include writhing, twisting movements of the face, limbs, and body. ​Movements get worse with disease progression.​ Aspiration and malnutrition are likely due to the involuntary movements affecting speech, chewing, and swallowing. ​ Client Care​ Treatment is palliative​. Drugs are available to control the movements and behavioral problems .​ Nondrug therapies: counseling, memory books, and group activities​ Caloric needs are high.​ The constant chorea movements make the body burn through energy quickly. ​ A client with HD may need as many as 4000 - 5000 calories a day to maintain their body weight. ​ End of life issues and desires need to be openly discussed with clients. ​ Establish goals of nursing management​ with the client. Provide the most comfortable environment possible to the HD client and their caregivers by keeping them safe, treating physical symptoms, and providing emotional and psychological support. ​

Prioritizing Hypotheses: Multiple Sclerosis​ A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. Based on this information, which nursing diagnoses for the client should the nurse prioritize?​ Impaired tissue integrity​ Impaired physical mobility Risk for activity intolerance​ Self-care deficit​

According to North American Nursing Diagnosis Association (NANDA), impaired physical mobility (IPM) is defined as a state in which the individual experiences a decreased ability to move independently (as cited in Carpenito-Moyet, 2016). The client's muscle weakness, muscle spasticity, and ataxic gait meet the defining characteristics for this nursing diagnosis. Based on the client's impaired physical mobility, they may have a self-care deficit, making it a lower priority diagnosis.​ Risk for activity intolerance and impaired tissue integrity are also not the highest priority concerns for this client based on the information provided.​ Reference

Meet George George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 2 / 2 Sharon asks the nurse what other manifestations to expect now that George has a confirmed diagnosis of early Parkinson's disease. Which response is best? Select all that apply.​ Hypertension Dysphagia Diarrhea Rigidity Bradykinesia​

Akinesia, or the absence or loss of control of voluntary muscle movements, is what causes the dysphagia and lack of arm swinging when walking. Bradykinesia is a common manifestation of PD, as well as rigidity. Remember, PD is a "TRAP" (tremors, rigidity, akinesia, postural instability)—the client is trapped in their own bodies and cannot move the way in which they would like to.

Pharmacology for Parkinson's Disease Unfortunately, Parkinson's disease (PD) does not have a cure. This means that the focus of care is shifted to symptom management to maintain and promote the client's overall wellbeing. ​ Drug therapy and management is a first-line defense for the management of PD symptoms. The goal of the drug therapy is to correct the neurotransmitter imbalance that is associated with the development of PD.

Antiparkinsonian Medications Dopaminergic medicationsEnhance the release of dopamine. ​ Anticholinergic medicationsBlock the effect of the extra/overreactive cholinergic neurons ​ Levodopa Levodopa is the chemical precursor of dopamine and is converted to dopamine in the basal ganglia of the brain. Levodopa with carbidopa is the primary medication treatment for symptomatic clients. There are many side effects with levodopa with carbidopa, as well as many drug interactions. Prolonged usage often results in bradykinesia and periods when the medication will unpredictably stop or start working. With this inconsistency, healthcare providers may add a dopamine receptor agonist (a drug that stimulates dopamine production directly) into a client's medication regime, like ropinirole or pramipexole. Anticholinergic Medications Anticholinergic medications, like benztropine, decrease the activity of acetylcholine, reducing the excitatory messages being received. Antihistamines, like diphenhydramine, also can have an anticholinergic effect The use of only one drug to help manage PD symptoms is preferable, as it is easier to adjust one drug than when several drugs are combined. However, as the disease progresses, combination therapy may be necessary. Excessive amounts of dopaminergic drugs can worsen symptoms, also known as paradoxical intoxication. ​

Nursing Assessment: Lorena Patient Information Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Is this just my mom aging? I don't know how to help her." The nurse is evaluating Lorena's judgment and cognitive reasoning abilities. Which of the following questions asked by the nurse would provide valuable insight for Lorena's case? Valuable Not Valuable "If you smelled smoke in your house, what would you do?" (Holding up a watch) "What is this object?"​ "Tell me a story from when you were a child."​ "I have drawn a circle. I want you to draw the face of a clock."​ "What did you have for breakfast today?" ​

Asking Lorena about smelling smoke or fire in her home and her reaction is assessing her judgment and cognitive abilities. Remember that clients with Alzheimer's disease (AD) and dementia have concerns with judgment and safety. Naming common objects, such as a watch or a pencil, also assess a client's cognitive patterns. Drawing the face of a clock is a common assessment for the Mini-Cog exam, a brief assessment tool for cognitive impairment. Asking the client to recall from their childhood or earlier that day is not assessing cognitive abilities, but their memory. ​

Autonomic Dysreflexia Another major complication that can arise with any spinal cord injury (SCI) is the concept of autonomic dysreflexia (AD). This life-threatening emergency occurs in clients with cord injuries at the sixth thoracic vertebrae (T6) or higher. AD is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system (SNS). The most common precipitating factor of AD involves a distended bladder or rectum, but any sensory stimulation can cause AD. Here's what happens: ​

Autonomic Dysreflexia

Plan of Care ​ Charles Lee​ 40-year-old male​ Allergies: Penicillin Past Medical History: Hypertension (noncompliant), asthma, 30 pack year smoking history, cocaine abuse Charles arrives to the emergency department (ED) complaining of the "worst headache of his life", while clutching his head and writhing in pain. The nurse assesses Charles' vital signs, and currently his blood pressure is 220/140 mmHg, heart rate 104 beats per minute, and respiratory rate of 18 breaths per minute. What does the nurse expect to see in Charles' plan of care? Select all that apply. Administer seizure prophylaxis. Gather an informed consent form for surgery. Perform neurologic evaluation. Prepare Charles for a computerized tomography (CT) scan. Administer tissue plasminogen activator (tPA).

Based on Charles' statement of the "worst headache of his life", he needs to be immediately evaluated for a hemorrhagic stroke. This would include neurologic assessments, and a CT scan. Informed consent for surgery would be appropriate as the most common causes of hemorrhagic strokes are ruptured cerebral aneurysms, and surgery must be done to relieve the pressure building on the brain. Seizure prophylaxis is also an appropriate prescription as the blood on the brain from the hemorrhagic stroke can irritate the meninges and brain tissue, causing a potential seizure. Administering any thrombolytic or fibrinolytic therapy for hemorrhagic client is contraindicated, as they can further the bleeding

Nursing Management: Altered Intracranial Regulation​ The client is admitted due to altered intracranial regulation. The client has headache and the temperature of 102 degrees Fahrenheit. What are the most appropriate nursing actions? Select all that apply. Administer antacid and proton pump inhibitors. Administer acetaminophen IV every 4 hours as needed. Administer opioids every 4 hours for pain as needed. Intubate the client immediately and monitor oxygen saturation. Provide a quiet, non-stimulating environment. Monitor the headache and assess by using PQRST scale.

Based on the client case scenario, the client has headache and hyperthermia. To stabilize the headache, provide a quiet, non-stimulating environment, monitoring and assessing it using PQRST scale is important and administering opioids for pain. To stabilize hyperthermia, administering acetaminophen will help reduce the body temperature.

Dementia Definition Cause Dementia is a disease process characterized by a decline from a previous level of function in one or more than one of the following cognitive domains: ​ attention​ language​ learning and memory​ executive function​ social cognition​ perceptual-motor ​ The declined cognition interferes with the person's ability to function and perform activities of daily living (ADLs). This decline does not come with any acute states of confusion (like delirium), or with the onset of another major mental disorder (like depression). Alzheimer's disease (AD) is the most common form of dementia. ​

Cause Dementia itself is caused by both treatable and untreatable conditions. The conditions can range from neurodegenerative diseases (like AD, Down syndrome, and Parkinson's disease), medication usage, or autoimmune disease processes (like multiple sclerosis, meningitis, or acquired immunodeficiency [AIDS]). Head injuries, hydrocephalus, brain tumors, or alcohol use disorder can also play a role in the development of dementia. You can see that the diagnosis of dementia can be attributed to multiple different factors and disease processes. Understanding the type of the cause of a client's dementia will help healthcare providers determine if it has a treatable or untreatable etiology, and if the dementia is potentially reversible. ​

Client Education: Altered Cognition​ Which priority intervention should the nurse include in the plan of care for the client experiencing altered cognition who is living with family. Plans to involve the client in group therapy sessions Detailed education on the risk factors associated with altered cognition Options to support the client and family with care An introduction of new leisure-time activities

Caring for a family member with altered cognition can be emotionally, mentally, and physically challenging. When the relationship is that of a parent and child, the reversal in family roles can cause conflict as the child takes on the authority role due to the altered mental state of the parent. Assisting the caregivers during the transition to the new role, helping them adjust to new normal routine, and connecting them with resources in the community is a key role of the nurse.

Diagnostic Tests: Altered Intracranial Regulation​ The client will undergo cerebral angiography early in the morning. What is the most important assessment finding that needs immediate attention? History of heart failure History of orthostatic hypotension History of lower limb amputation History of peptic ulcer disease

Cerebral angiography is a serial x-ray visualization of the intracranial and extracranial blood vessels to detect any vascular lesions or brain tumor. It uses contrast. Catheter is inserted into the femoral area. It is vital to assess the client's stroke risk because thrombi might be dislodged. The stroke risk factors include hyperlipidemia, hypertension, smoking, diabetes mellitus, physical inactivity, overweight/obesity and heart failure. Client needs to be nothing by mouth (NPO). Contrast will be used. Client needs to completely lie down during the procedure. Monitor neurologic status and vital signs as per protocol. Assess for bleeding.

Priority Action ​ Charles Lee​ 40-year-old male​ Allergies: Penicillin Past Medical History: Hypertension (noncompliant), asthma, 30 pack year smoking history, cocaine abuse The nurse is completing a neurologic assessment on Charles. The nurse notices that his pupils are fixed at 6mm and he is no longer following commands. What is the priority action for the nurse to take? Obtain Charles' blood pressure and heartrate. Prepare Charles for a chest x-ray Contact the healthcare provider. Stop any intravenous medications that are currently infusing.

Charles' pupils have increased in size and are no longer reacting to light. He is also not following commands. With an acute neurologic status change such as this, the nurse needs to notify the healthcare provider immediately. Charles needs to be evaluated for further bleeding or pressure building up in his skull (increased intracranial pressure (ICP).

Nursing Care: Altered Cognition Which of the following nursing interventions is most helpful in meeting the needs of an inpatient client with altered cognition? Ensuring a quiet environment with minimal distractions Developing a consistent nursing plan with fixed time schedules to provide for emotional needs Providing a nutritious diet high in carbohydrates and protein Providing an opportunity for many alternative choices in the daily schedule to stimulate interest

Clients with altered cognition should be provided with an environment that is quiet to decrease potential distractions that may increase confusion. While a nutritious diet is beneficial, the ratio of carbohydrates, proteins, and fats should be based on their physical, not cognitive, condition. A consistent plan of care to provide emotional support and promote safety should be flexible enough to support the client as their need arises, not on a fixed schedule. Clients with altered cognition may become overwhelmed when presented with too many choices when making decisions. ​

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 3 / 6 The nurse is preparing George for discharge home. She is observing his wife, Sharon, while at the bedside. Which action, if performed by Sharon, is promoting George's independence and autonomy in his care? Replacing George's button-up shirts with those that have a large zipper Cutting up George's dinner and feeding him Allowing George to keep track of his own medication schedule

Clothing items and the act of getting dressed can be a source of frustration for clients with Parkinson's disease (PD). Replacing things with buttons can help decrease this feeling. Sharon is ultimately promoting and assisting the maintenance of George's independence with this change, however, something that cutting up and feeding George his dinner would not accomplish. ​ Allowing George to keep track of his own medication schedule may not be appropriate for the long-term. Remember that clients with PD can have lapses in memory, confusion, and changes in mental status. It will be safer for Sharon or a healthcare professional (like a home health nurse) to help manage the medication schedule. ​

Myasthenia Gravis (MG) Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. This causes fluctuating weakness of certain skeletal muscle groups that affects over 60,000 people in the United States. So, what is happening?​ View the video below to find out.

Common Manifestations Weakness of skeletal muscle includes those used to move the eyes and eyelids (Ptosis is common), chew, swallow, speak, and breathe​ No sensory loss occurs​. Reflexes are normal. ​ Muscle atrophy is rare. Diagnostics Good history and physical. ​ Electromyography (EMG) focusing on muscle contractions.​ Tensilon test​Client receives an IV dose of Tensilon (anticholinesterase agent, which blocks the enzyme that breaks down ACh). ​If the client rapidly improves after administration of Tensilon, it can indicate positive diagnosis of MG. Client Management​ Drug Therapy consists of anticholinesterase agents (enhance transmission at neuromuscular junction), corticosteroids, and immunosuppressants.Pyridostigmine: most successful drug for long-term treatment ​ Plasmapheresis directly removes circulating antibodies, leading to a decrease in symptoms. MG can affect a client's skeletal muscles that help with breathing, so a good and continued respiratory assessment is key. ​ Focus care on the neurologic deficits and their impact on the client's daily living. ​ The client's diet may need to be altered due to the muscle weakness associated with chewing and swallowing (semisoft foods instead of liquids or solids).​ Plan periods of rest after activity. ​ Schedule doses of drugs to reach peak action at mealtime (may make eating easier and less tiring).

Diagnostic Tests: Blood Tests​ The blood tests can help to suggest underlying cause/s of altered intracranial regulation. Reviewing these results may help in planning nursing actions.​ Complete Blood Count Reasons The complete blood count is a series of individual tests that look at white blood cells, red blood cells, and platelets. Increased white blood cells can signal infection, while decreased red blood cells, hemoglobin, and platelets can suggest anemia or hypoxemia. Nursing Considerations Antibiotics, blood transfusion, or oxygen may improve a client with these abnormalities.​

Comprehensive Metabolic Panel​ Reasons The comprehensive metabolic panel consists of over twenty different electrolytes, protein, and liver function tests. High or low electrolyte levels can cause confusion. Elevated liver function can suggest liver failure, and decreased protein levels can mean malnutrition. Nursing Considerations Correction of electrolytes, treatment of liver failure, or improved nutrition may improve a client with these abnormalities. Magnesium or Phosphorus​ Reasons These electrolytes are not usually included in combination panels, and can cause altered intracranial regulation if abnormal. These electrolyte levels can be decreased in renal failure, dehydration, or alcohol misuse. Nursing Considerations​ Correcting these electrolyte levels may improve a client with these abnormalities.​ Ammonia Level​ Reasons During liver insufficiency and failure, ammonia levels can increase. Increased ammonia levels can cause acute confusion resulting from altered intracranial regulation. Nursing Considerations​ Reducing ammonia levels in liver failure may improve a client with liver failure. The blood test needs to be frozen immediately after collection.​ Arterial Blood Gas Reasons Measure levels oxygen and carbon dioxide levels which can affect pH and lead to increased cerebral edema (swelling of the brain). Nursing Considerations Reducing carbon dioxide levels and/or increasing oxygen levels may improve a client with these abnormalities. This test involves an arterial puncture; it is important to hold pressure on the arterial site for 5 to 10 minutes to ensure homeostasis.​

Diagnostic Tests: Non-Invasive Tests The diagnostic tests help to determine the underlying cause of altered intracranial regulation. These tests offer little or no risk of complications because they are considered "non-invasive". Results of these tests can help to determine severity, improvement, and help manage the client.​ Computed Tomography (CT) Scan With or Without Contrast​

Computed Tomography (CT) Scan With or Without Contrast​ This scan takes "slices" of x-rays approximately 1 millimeter each over an area of the body. This is a detailed picture of bones or organs. Nursing Considerations​ If the CT scan uses contrast, clients need to be assessed for any iodine or shellfish allergies. Hold metformin for 48 hours prior the procedure. Hydrate the client after the procedure.​ Magnetic Resonance (MR) Scan Magnetic resonance imaging used powerful magnets to take "slice" images. Unlike a CT scan, no radiation is involved. This gives the clearest picture of any type of bone, organs, nerves, tendons, or ligaments. Nursing Considerations​ Prior to the procedure, the client needs to be assessed for any presence of metal, including implanted electronic devices (i.e., pacemakers). The client may need medication for anxiety or claustrophobia due to the loud test and narrow space.​ Positron Emission Tomography (PET) Scan This measures the metabolic activity of the brain using a radioactive isotope which is injected prior to the procedure. This is useful for identifying malignancies that take up the sugar-based isotope for metabolism. Nursing Considerations Prior to the procedure, instruct the client not to take any sedatives or tranquilizers. Have the client empty the bladder. Inform the client that during the procedure, the client may be asked to do different activities.​ Electroencephalogram (EEG)​ This records electrical activity in the brain. Electrodes are connected to several areas of the skull to review this activity from different angles. Nursing Considerations Certain medications may be withheld to get a more accurate recording (tranquilizer or anti-seizure drugs). The client may have paste in their hair after the procedure is completed.​ Transcranial Doppler​ This test uses ultrasound to evaluate blood flow of the intracranial blood vessels. By measuring the speed of the blood flow, or identifying narrowing in a vessel, potential blockages can be identified. Nursing Considerations​ No preparation is usually needed.​

Intracranial Pressure and Perfusion​

Definition Intracranial pressure (ICP) is the pressure inside the skull. It can be measured by an intracranial pressure monitor and affected by changes in the brain. Indications Intracranial pressure changes whenever brain tissue, cerebrospinal fluid, or blood volume is increased or decreased (for example: brain tumor, meningitis, encephalitis, head injury, and stroke). Any increase in the amount of brain tissue, cerebrospinal fluid, or blood can increase the intracranial pressure in the brain. Because CPP=MAP-ICP, when intracranial pressure (ICP) goes up, the client's cerebral perfusion pressure (CPP) will decrease while the overall MAP remains the same.

Meet Eliza Patient Information Eliza Grady ​ 56-year-old female ​ Allergies: Latex​ Past Medical History: Huntington's disease, asthma, anxiety Eliza is at her healthcare provider's office with her husband, Paul. Eliza reports that her spasticity and involuntary movements have been manageable with the addition of a new medication, but she is afraid her erratic movements scare her grandchildren. Eliza excuses herself to the restroom, and Paul mentions to the nurse, "Eliza has seemed so much more withdrawn lately. She seems to not even want to spend time with our family and friends". ​ ​What is the priority nursing diagnosis for Eliza? Hopelessness Impaired communication Imbalanced nutrition: less than the body requires​ Risk for injury related to the spasticity

Depression and social withdrawal are common for clients with Huntington's disease (HD). Aside from pneumonia, the second leading cause of death for HD clients is suicide, so any changes in Eliza's mental health needs to be taken seriously. A priority nursing diagnosis for Eliza at this time would be related to hopelessness, due to her withdrawal of family and friends, and the anxiety related to her movements scaring her grandchildren. ​ While she may have issues with malnutrition and risk for injuries related to her disease process, her mental health is the priority at this time.

Alzheimer's Disease Alzheimer's disease (AD) accounts for 60%-80% of all dementia cases. This chronic and progressive neurogenerative brain disease is the sixth leading cause of death in the United States. It is a fatal disease process with no cure. ​ Causes and Risk Factors Unfortunately, the direct cause of AD is unknown. Research has shown that: The greatest risk factor for the development of AD is aging. Most clients diagnosed with AD are over the age of 65 years old. With that being said, AD is not a normal part of aging. Family history and genetics have also been linked to the development of AD. A client with a first degree relative (like a parent or sibling) with dementia are more likely to develop the disease. Poor cardiovascular health can impact brain function due to the lack of nutrients and oxygen being delivered with poor blood supply or vasculature. ​ As a part of the aging process, people develop plaques in their brain tissue. These plaques can disrupt communication between nerve cells, causing decreased transmission, and increase brain inflammation. With the client with AD, these plaques appear in certain parts of the brain—primarily in the areas of memory and cognitive function. Eventually, these plaques infiltrate the cerebral cortex, which assists with language and reasoning. Neurofibrillary tangles with a certain protein (called Tau) are found in the neurons on clients with AD. Neuronal death also occurs in AD, which causes structural damage to the brain. The affected locations in the brain begin to atrophy, and by the final stage of AD, the brain tissue has shrunk significantly. ​

Diagnosis Tests There is no one definitive diagnostic exam for AD. The diagnosis is usually one of exclusion (everything else doesn't fit). This evaluation includes a complete health history, physical examination, neurologic and mental status assessments, and laboratory monitoring. A definitive diagnosis of AD requires an examination of brain tissue at an autopsy to find the neurofibrillary tangles and plaques. ​ Medications While pharmacologic interventions are available, no medication will cure or reverse the progression of AD. The medications prescribed only help slightly decrease the rate of decline in cognitive function. Cholinesterase inhibitors, such as donepezil and rivastigmine are commonly offered. Memantine protects the brain's nerve cells against cell degeneration and is another pharmacologic option. Treating a client's depression that is often associated with AD may improve their cognitive abilities. Adding a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine or citalopram may be appropriate. The antidepressant trazodone may help with problems related to sleep.

Seizure Precautions The nurse is preparing to admit a client who will be placed on seizure precautions. What equipment would be important for the nurse to gather? Select all that apply. Tongue-blade​ Urinary catheter ​ Crash cart Pads for the bedrails Oxygen equipment​ Suction set-up

For clients on seizure precautions, the nurse's focus is on providing an environment that protects the client during a seizure (padded side rails) and places emergency equipment at the bedside for postictal care (oxygen and suction equipment).​ A tongue-blade, which was used to prevent the client from biting their tongue during a seizure in the past is not needed and may cause harm if forced into the mouth during a seizure. The crash cart, with emergency resuscitation equipment, is usually not needed to provide care during or after a seizure. Although a client may lose bladder control during a seizure, a urinary catheter is not needed to assure their safety.​

Pharmacotherapy: Altered Intracranial Regulation​ The client is admitted due to head injury. The client had episodes of seizures. What will be the most appropriate nursing action? Administer propofol IV infusion for sedation. Administer lorazepam IV push as needed for seizures. Administer amiodarone IV infusion for arrhythmias. Administer pantoprazole IV push for peptic ulcer.

For a client that has seizure episodes, lorazepam will help to stop seizure. However, further assessment is needed to avoid seizure episodes to happen again. Pantoprazole will decrease gastric acid secretion. Amiodarone is an anti-arrhythmic medication while propofol is for sedation.

Parkinson's Disease Parkinson's disease (PD) is a progressive, chronic neurodegenerative disorder that impacts a large community. Almost 60,000 people in the United States are diagnosed with PD each year. ​

Genetic Risk Factors PD is characterized by slowness of muscle movement (bradykinesia), increased muscle tone (rigidity), tremors at rest, and gait changes. Unfortunately, the exact cause of PD is unknown. Although PD is not officially classified as a hereditary condition, genetic risk factors should be evaluated. About 15% of all clients with PD have it in their family history. A deficit in dopamine occurs in clients with PD. This deficit creates an imbalance between dopamine and acetylcholine, an excitatory neurotransmitter. Acetylcholine is an excitatory neurotransmitter that assists with muscle contractions. With the imbalance of dopamine in PD clients, there is an abundance of acetylcholine left to create excessive and inappropriate muscle movements (like the tremor and rigidity you see with PD). ​ Watch the videos below to learn how the deficit in dopamine cause clients' movement problems. Khan Academy-Putting It All Together: Pathophysiology of Parkinson's Disease (Giles, 2015) [Video] (5:58) Parkinson's Disease, Animation (Alila Medical Media, 2018) [Video, Note: The video will start playing at 0:30.) Complications Parkinson's disease itself is not fatal, but the complications can be very severe. As the disease progresses, the complications increase. Motor symptoms such as dyskinesia (spontaneous involuntary movements), weakness, neurologic issues, and neuropsychiatric concerns like depression and hallucinations are common. As PD progresses, dementia often results and is associated with increased mortality. Malnutrition is also of concern for PD clients, as weakness affects safely swallowing. Dysphagia can lead to aspiration as well as other malnutrition states. Skeletal muscle weakness leads to immobility, which puts the PD client at increased risk for skin breakdown and pressure ulcers, urinary tract infections (UTIs), and pneumonia. Orthostatic hypotension is common.

Nursing Management The client is admitted due to altered intracranial regulation. The client has cranial nerve IX and X dysfunction. What should the nurse do first? Assist the client to ambulate in the bedside commode. Intubate the client immediately and give oxygen. Withhold oral fluids and food immediately. Apply antibiotic eye ointment every 4 hours.

If the client has cranial nerve IX (glossopharyngeal) and X (vagus) dysfunction, this means that the gag and swallowing reflexes of the client is compromised. Therefore, withholding the oral fluids and food are very important to promote client safety. Applying antibiotic eye ointment is not applicable based on the case scenario. Assist the client to ambulate is important to but not directly related to cranial nerves IX and X. Intubate the client and giving oxygen are not necessary yet until the client had trouble of breathing.

Meet MaryAnn Patient Information MaryAnn Long​ 62-year-old female ​ Allergies: none​ Admitting Diagnosis: Bacterial pneumonia ​ Past Medical History: Multiple sclerosis (MS)​ Current Medications: baclofen, interferon-β MaryAnn is being admitted to the medical-surgical unit for pneumonia. What impact on MaryAnn caused by pneumonia should the nurse anticipate? The history of multiple sclerosis does not allow for antibiotics to be given.​ The pneumonia will not allow for MaryAnn to get treatment for her multiple sclerosis.​ MaryAnn's current prescription of interferon-β will treat the pneumonia. The pneumonia may make MaryAnn multiple sclerosis symptoms worse.

Infections, especially respiratory or urinary tract containing infections, are common triggers that may worsen multiple sclerosis (MS). Therefore, an important part of client education for those with MS includes avoiding these infections and other triggers as good as they can.

Priority Intervention​ The nurse is caring for an elderly client with current sodium level of 121 mEq/L. The client also has a history of congestive heart failure and alcohol abuse. He has not been sleeping during his time in the hospital. During an assessment, the client becomes increasingly agitated towards staff, refusing to believe that he has been in the hospital for weeks. Which intervention is most appropriate for the nurse to implement? Administer haloperidol intramuscularly (IM) per prescription​ Check the client's chart to see if any medications could be causing this behavior change Restrain the client and contact the primary care provider Attempt to reorient the client and use therapeutic communication

It appears that this client is suffering from delirium, related to the electrolyte imbalance, sleep deprivation, and past medical concerns. The priority intervention the nurse should attempt would be to reorient the client, using calming techniques and therapeutic communication as to not overwhelm the client further. Restraining the delirious client only increases their risk of harming themselves. Haloperidol or other pharmacologic interventions should be used only when non-pharmacologic interventions have failed, as they may worsen the client's delirium.

Plan of Care ​for Jonathan Patient Information Jonathan Bennis ​ 46-year-old male ​ Allergies: none​ Admitting Diagnosis: exacerbation of myasthenia gravis (MG)​ What interventions are important for the nurse to include in Jonathan's plan of care? Select that all apply. Administer Jonathan's dose of pyridostigmine after lunch.​ Plan for options for meals, such as substituting Jell-O for chicken broth. Schedule physically demanding activities earlier in the day.​ Protect the extremities due to poor circulation.​ Restrict Jonathan's fluids to 1,000 ml/day.

It is going to be incredibly important for Jonathan to have periods of rest after activities, especially since his muscle weakness is progressive throughout the day. This is why it is important to schedule physically demanding activities earlier in the day. We also want to plan options for meals, as his diet may need to be altered due to the muscle weakness associated with chewing and swallowing. This is why a semisolid food, such as flavored gelatin, may be easier for Jonathan to handle than a liquid (broth). ​ Myasthenia gravis (MG) does not cause impaired circulation, and we do not need to restrict fluids. It is better to schedule medications to have their peak impact/effect at mealtime, so the process of eating is not too tiring for clients with MG.

Meet Lorena Patient Information Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Mom has been more confused over the last couple of days, to the point where she gets agitated for hours at a time and does not sleep. My sister and I are staying with her 24 hours a day, and we are all exhausted. Should we be doing something different for her?" Based on Lorena's case, what information will the nurse need to gather? Select all that apply​. What medications Lorena is taking What Lorena's daily diet consists of Detailed account of what cognitive changes have occurred​ Lorena's present and family medical history The number of children Lorena has had

It is important for the nurse to gather information regarding Lorena's change in behavior and mentation before making any statements to Elizabeth. The nurse should inquire about Lorena's present and family medical history, any medications she currently takes, and a detailed description of what the memory or behavioral changes that Elizabeth has noticed are. ​ Lorena's diet and the number of children are not closely related to understanding potential dementia and are not the priority at this time.

Nursing Diagnosis​ George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 1 / 2 At this time, which primary focus for George's plan of care should the nurse select? ​ Educate George and Sharon on the benefits of a deep brain stimulator (DBS)​. Initiate seizure precautions for George. Promote exercise and encourage nutritional intake. Ask the healthcare provider for a sedative in case George becomes agitated.

It is more important to encourage nutritional intake and promote exercise for George since his diagnosis. Physical exercise and activity may help the client remain independent for a longer period of time, and malnutrition is a common complication found in Parkinson's and needs to be addressed. ​ Educating about the deep brain stimulator or a sedative are not appropriate at this time as they are not indicated in George's plan of care. Seizure precautions are also not appropriate or warranted for George

Prevention: Stroke Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity The nurse is educating Janet about her recent transient ischemic attack (TIA). Janet asks, "How can I keep that from happening again?" How should the nurse respond? Select all that apply. ​ Initiating a strenuous exercise program ​ Healthy diet Blood pressure management​ Health screenings only when sick Diabetic disease control​

It is very important for Janet to understand why her risk factors put her at risk for a transient ischemic attack. Her atrial fibrillation and obesity put her at an increased risk. A healthy diet, coupled with blood pressure management and diabetic disease control​ will decrease her risks of a TIA occurring again. Initiating a strenuous exercise program is not recommended for Janet with her current physical state, and health screenings are required more frequently given her health history.

Taking Action​ Jerry has just been admitted to the medical surgical unit after a traumatic motor vehicle collision (MVC). The nurse is assessing Jerry's vital signs every two hours. When the nurse enters the room, Jerry appears anxious and emotional. He says, "I haven't been able to sleep because every hour someone comes in my room and wakes me up! What do you want now?!" Which of the following is the best intervention provided by the nurse?​ Remind Jerry that he is in the hospital and requires frequent monitoring Apologize and leave Jerry's room Call security to help restrain Jerry Discuss changing the schedule for Jerry's vital signs with the healthcare provider

It may be the time to discuss with the healthcare provider regarding changing the frequency of assessments. With Jerry's uneventful admission thus far, does he still need vital signs assessed every 2 hours? A good, objective discussion with the healthcare provider may help Jerry get more restful time, as well as build the rapport with him that the healthcare staff do care about his well-being. ​

Meet George George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 1 / 2 Which intervention should the nurse anticipate for George's immediate plan of care? Draw blood for cultures Obtain electrocardiogram (ECG) Magnetic resonance imaging (MRI) Thorough history and physical assessment ​

It seems that George is exhibiting classic manifestations of Parkinson's disease (PD). Since there is no single diagnostic test or exam available for PD, diagnosis is made off of a thorough history and physical assessment, including neurologic exam, discussion of family history, and current medications. The other prescriptions are not appropriate for George's presentation at this time.

Meet Janet​ Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity Janet is visiting the clinic for an annual health screening. She has been feeling sluggish and has recently gained weight. A few weeks ago, Janet reported having minor stroke-like symptoms including facial droop and confusion, but they subsided within an hour. She is asking the nurse what to do if those symptoms arise again. Which statement by the nurse is most appropriate?​ "The symptoms are not a concern because they subsided within an hour and you have no deficits." "Because you do not have a family history of stroke, there is nothing to be concerned about."​ "Wait to see if the symptoms persist after an hour and if they do, call your healthcare provider's office."​ "If you experience facial droop and confusion again, you need to contact 911 and seek medical treatment immediately."

It sounds like Janet suffered from a transient ischemic attack (TIA) a few weeks ago. This is associated with stroke like symptoms that resolve within 60 minutes. The problem is that it is impossible to know if the symptoms will subside or not, which would indicate an ischemic stroke. It is imperative that Janet understands if that happens again, she must seek medical attention as soon as symptoms are recognized. TIAs are a medical emergency! ​

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 6 / 6 George tells the nurse, "I know that I may have some mental status changes with my Parkinson's disease. I want Sharon to be able to make decisions for me if that happens." Which is the best response of the following should be provided by the nurse? Encourage George to see a lawyer after he is discharged from the facility. Request that the healthcare provider come to the bedside to talk with George. Provide George and Sharon information about an advanced directive. Document George's wishes in his medical record​.

It's a good thing that George is thinking about this situation ahead of time. Providing George and Sharon with information regarding an advanced directive is appropriate at this time. This document will allow George to stipulate his wishes, if he is unable to communicate them. ​ Requesting that the healthcare provider come to the bedside is not needed. It is out of a nurse's scope of practice to alter or add to a client's comfort status, or change their decision-making abilities. ​

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 5 / 6 Which statement made by George indicates an understanding of his long-term treatment plan with Parkinson's disease (PD)? "I will limit my fluid intake to no more than 2 liters a day." "I understand that if medications don't work for me, I may need surgery to help with my tremors and slow movement." "I will eat three large meals a day so that I can rest more during the daytime."​

It's a good thing that George seems to understand that there are other options for management of his Parkinson's disease (PD) if medications do not work. He is referring to surgical implantation of a deep brain stimulator (DBS). A DBS is programmed to deliver a specific current to the brain to treat tremors and uncontrolled movements of PD. ​ Clients with PD should be encouraged increase their fluid intake, not restrict it, and to have smaller, more frequent meals throughout the day.

Meet Jordan Omar Patient Information Jordan Omar 19-year-old male Allergies: None Past Medical History: Asthma Reason for Visit: Crashed all-terrain vehicle (ATV) into a tree and was not wearing a helmet. Jordan arrives to the emergency department (ED) accompanied by a group of friends. He is conscious, but unable to move his lower extremities. The nurse and nursing student are preparing to admit Jordan and start his assessment. Which action, if made by the nursing student, will require the nurse to immediately intervene? The nursing student asks Jordan to grab the bedside rail and try to roll over so that they can assess his back.​ The nursing student collects information about the accident from Jordan's friends. The nursing student scolds Jordan for being reckless. The nursing student asks the group of friends to quietly wait out in the hallway while they complete their assessment of Jordan.​

It's good that Jordan is being evaluated and still conscious, but the lack of movement in his lower extremities is concerning. Remember that in assessing and admitting any client who is suspected of having a spinal cord injury (SCI), the priority is immobilizing the head, neck, and spine with a rigid cervical collar, and "log rolling" the client as a unit. The nursing student asking Jordan to grab the side rail and twist to roll over is absolutely inappropriate and unsafe with his condition. This will require immediate intervention from the nurse. Additionally, it is not appropriate for any member of the health care to judge the actions of clients, even if those actions led to their current alteration in health.​

Communication ​ Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity After tissue plasminogen activator (tPA) is administered to Janet, her neurologic status begins to improve. She is now struggling with expressive aphasia. What interventions would be most appropriate to help Janet communicate? Select all that apply. Cluster nursing care so Janet has to communicate less frequently. Minimize background noise. Ask 'yes' or 'no' questions. Prevent embarrassment by answering for Janet if she doesn't respond quickly. Use a loud tone of voice when communicating with Janet.

It's great to hear that Janet's neurologic status begins to improve! But she is now experiencing expressive aphasia. It is important to give Janet time to respond- remember, this is not the time to be impatient. Use simple, short sentences to aid in comprehension, and structure your conversations so that it allows the client to use simple responses, like "yes" or "no". Minimizing background noise will help Janet obtain the nurse's entire message, and allow for full comprehension. There is no need to speak in a loud tone of voice and Janet's hearing is not the issue- it is the language center of the brain. Clustering care is commonly overwhelming for neurologic clients, and may not be appropriate.

Collaborative Interventions: Spinal Cord Injury Patient Information Jordan Omar 19-year-old male Allergies: None Past Medical History: Asthma Reason for Visit: Crashed all-terrain vehicle (ATV) into a tree and was not wearing a helmet. It has been 24 hours since Jordan's accident. Which collaborative interventions would the nurse anticipate to include in his care? Select all that apply. ​ Indwelling urinary catheter care Administration of proton pump inhibitors (PPI)​ Continuous cardiac monitoring Maintaining cool room temperature Initiating physical therapy regimen

It's important to constantly monitor for Jordan, including cardiac monitoring and frequent assessments. Performing indwelling urinary catheter care will help decrease the risk of Jordan developing a catheter acquired urinary tract infection (CAUTI), which would complicate his care. Stress ulcers develop in clients with spinal cord injury (SCI) due to the physiologic response to severe trauma and stress, so administration of proton pump inhibitors (PPI) would decrease the hydrochloric acid (HCl) secretion from Jordan's stomach. ​ A cool room temperature is not appropriate for the client with SCI, as they have problems regulating their own body temperature. A warm room temperature would be most appropriate. ​ Twenty-four hours after injury, the spinal cord is still swelling, so physical therapy regimen is not appropriate at this time.

Nursing Diagnosis ​for MaryAnn Patient Information MaryAnn Long​ 62-year-old female ​ Allergies: none​ Admitting Diagnosis: Bacterial pneumonia ​ Past Medical History: Multiple sclerosis (MS)​ Current Medications: baclofen, interferon-β MaryAnn has a nursing diagnosis of self-care deficit related to her disease progression and weakness. Which intervention should the nurse include in MaryAnn's plan of care? Provide all of MaryAnn's self-care for her.​ Encourage MaryAnn's input in planning her daily schedule.​ Put time limits on activities of daily living and self-care activities. Remove assistive devices so MaryAnn can increase her muscle strength.​

It's important to include MaryAnn in her own care planning to increase her quality of life and interest in her care. With her diagnosis being a progressive one with no cure, MaryAnn will need to learn to adjust to the progressive changes of her disease and adapt. Allowing her to use assistive devices if she requests/requires them and giving her ample time while not rushing her will promote independence and a sense of control. Providing all of MaryAnn's care for her may cause frustration over her loss of independence.

At Risk ​ Which client below is most at risk for the development of an ischemic stroke? Transcript Link Darren Harken Parker Gant Janet Singer Melanie Martin

Janet has multiple risk factors associated with ischemic strokes, including atrial fibrillation and obesity. Her age is also a risk factor. The other clients do not have as much of a risk for ischemic strokes compared to Janet.

Priority Nursing Actions: Janet​ Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity Janet comes to the emergency department three weeks after her initial visit to the clinic. She was eating breakfast with her daughter, Emily, when she noticed that Janet was slurring her words, had right sided facial droop, and right sided weakness. In which order will the nurse implement these prescriptions? Obtain Janet's weight​ Obtain computerized tomography (CT) scan without contrast​ Administer tissue plasminogen activator (tPA) ​ Administer oxygen to keep Janet's oxygen saturation above 92%​

Janet has some pretty significant stroke like symptoms occurring. Using priority setting framework like airway, breathing, and circulation (ABC's), administering oxygen to Janet is the priority concern. Remember that stroke clients cannot protect their own airway readily and may need supplemental oxygen. Obtaining a CT scan will give healthcare providers an idea of what Janet's injury is, especially if they are considering administering tissue plasminogen activator (tPA). Because tPA is weight-based dosing, the nurse would need to obtain Janet's weight before administering the medication itself

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Janet's eyes did not open spontaneously when the nurse arrived at the room, but rather to her voice saying, 'good morning'. This scores Janet a "3" for "to speech" in best eye opening response category. When assessing her best verbal response, some of Janet's answers were incorrect. This would give Janet a score of "4" for verbal response, as she was confused. Inappropriate words would be if Janet responded to the question of where she is with something completely not related to the question. The final category, best motor response, Janet scored a "6" due to her following commands. So, her total GCS score is 13.

Interprofessional Care: Spinal Cord Injury Patient Information Jordan Omar 19-year-old male Allergies: None Past Medical History: Asthma Reason for Visit: Crashed all-terrain vehicle (ATV) into a tree and was not wearing a helmet. Diagnostic imaging results of Jordan's spine reveal a T4 (the fourth thoracic vertebrae) spinal fracture. ​ The physician asks the nurse to notify Jordan's parents that he is being admitted to the medical surgical unit. Which action by the nurse is most appropriate? Get their phone number from Jordan's chart and call his parents Contact Jordan's parents for consent to treat Ask Jordan if he wants his parents to be notified of his admission Request the healthcare provider to call and speak to the parents

Jordan is 19 years old, so he does not need parental consent. It would be more appropriate for the nurse to ask if Jordan wants his parents to be notified of his admission as it is not a requirement. If Jordan gives permission for his parents to be notified, the nurse can notify his parents.

Further Injury: Spinal Cord Injury Patient Information Jordan Omar 19-year-old male Allergies: None Past Medical History: Asthma Reason for Visit: Crashed all-terrain vehicle (ATV) into a tree and was not wearing a helmet. Upon assessment, the nurse notices that Jordan's wrist has an obvious deformity. It is painful upon palpation, and is beginning to swell and bruise. Based on this assessment, the nurse should understand which information is correct? The pain that Jordan feels in his wrist is phantom pain and not real​. Jordan does not have any feeling in his wrist, so the nurse does not have to worry about this injury. ​ Jordan still has innervation to his wrist and is feeling musculoskeletal pain that needs to be addressed​. Jordan has no innervation to his wrist so is unable to feel musculoskeletal pain.

Jordan's spinal cord injury (SCI) is at the fourth thoracic vertebrae (T4), so his upper extremities will still be innervated and functional. However, regardless of the level of injury, the musculoskeletal pain would still need to be addressed. Phantom pain is associated with amputations, so it is not something Jordan would be experiencing at this time. ​ Although a wrist injury is not the priority concern after Jordan's accident, it is still important to evaluate. Fractures, sprains, or strains can cause decreased perfusion to the extremity if not addressed, causing further damage and complication.

Planning Care: Lorena Patient Information Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Is this just my mom aging? I don't know how to help her." Based on the conversation with Elizabeth and observations of Lorena, which actions should the nurse recommend to Elizabeth to help decrease her mother's sundowning symptoms? Select all that apply. "Work on limiting the amount of caffeine that Lorena has in the afternoon." "Try to open blinds and turn on lights during the day to increase Lorena's exposure to daylight." "That is called sundowning, which is a symptom of your mother's disease. There is nothing you can do to help." "Allow Lorena to sit alone in her room quietly during the daytime for a nap." "Find time to sit quietly in a calm environment with Lorena around the late afternoon."

Lorena is experiencing sundowning, a specific type of agitation that accompanies dementia and Alzheimer's disease (AD). Management of sundowning can be challenging for caregivers and nurses alike. It is best for the sundowning client to avoid caffeine and naps and increase the amount of daylight they are exposed to. While the exact cause of sundowning is unknown, it may be due to a disruption in circadian rhyth

Priority Nursing Diagnoses: Lorena Patient Information Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Is this just my mom aging? I don't know how to help her". Which nursing diagnoses identified by the nurse are appropriate for Lorena's case? Select all that apply. Acute confusion Disturbed thought process Altered perception Risk for injury Imbalanced nutrition: more than the body requires

Lorena's Alzheimer's disease (AD) is not considered acute confusion, but chronic. A common issue for AD clients is malnutrition, with a lack of adequate nutritional intake. Impaired thought processes, altered perception, and risk for injury are all appropriate diagnoses for Lorena

Medications ​ Which medications should a nurse expect to see in a care plan for an elderly client with Alzheimer's disease (AD)? Select all that apply.​ Cholinesterase inhibitor​ Antipsychotic Diuretic Antidepressant​ Antihypertensive

Medications used to treat Alzheimer's disease (AD) include cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) for all stages and memantine for later stages. Antidepressants are used to treat depression in persons living with AD, though care should be taken to clearly determine that the client's symptoms are caused by depression rather than their dementia.​ The remaining medications listed are used to treat other health conditions

Assessment: Myasthenia Gravis Which assessment finding is most associated with myasthenia gravis (MG)? Muscle atrophy Tremors and bradykinesia​ Ataxia​ Muscle weakness that progresses with use

Myasthenia gravis (MG) is a neuromuscular disorder that causes weakness in the skeletal muscles, which are the muscles your body uses for movement. It occurs when communication between nerve cells and muscles becomes impaired and progresses over time. ​ Tremors and bradykinesia (slow movement) are associated with Parkinson disease. Ataxia is a degenerative disease of the nervous system caused by damage to the cerebellum. Many symptoms of ataxia mimic those of being drunk, such as slurred speech, stumbling, falling, and incoordination. Muscle atrophy is when muscles waste away. It's usually caused by a lack of physical activity. When a disease or injury makes it difficult or impossible for you to move an arm or leg, the lack of mobility can result in muscle wasting.

Interdisciplinary Team What member of a facility's interdisciplinary team would be best suited to assist a client with Parkinson's disease (PD) in maintaining their independence with activities of daily living (ADLs)? Nutritionist​ Case manager Physical therapist Occupational therapist

Occupational therapy is focused on helping clients retain their independence through the use of assistive devices (such as specialty silverware or toothbrushes) with activities of daily living. Physical therapy is more focused on mobility and safe transferring and positioning of clients. Nutritionists will be helpful with clients with PD, as malnutrition is a real risk for this population. ​

Nursing Assessment The nurse assessing an older adult should suspect the client has Parkinson disease (PD) based on which findings? Select all that​ apply. Slurred speech Facial expression shows no emotion Inability to recall breakfast Blood pressure increases when the client stands up Hand tremors at rest

PD causes slowed​ movements, including slurred speech. Tremors at rest are common in PD and easy to identify. Tremors may occur in the​ hands, face,​ neck, lips,​ tongue, and jaw. PD causes a​ frozen, mask-like expression​ (lack of​ affect). The client will not have an expression that is consistent with the emotions the client is feeling. Memory loss occurs in PD because of the loss of neurons and other changes in the brain. The client may develop dementia. ​ Postural​ hypotension, not​ hypertension, is a common manifestation in clients with PD. This is caused by damage to the autonomic nervous system.

Intracranial Regulation and Risk Factors Altered intracranial regulation can be related to many causes. Here are some cues from the client's history that may indicate regulation issues.

Past Medical History Head injury​ Brain hematoma (epidural, subdural, or subarachnoid)​ Cerebral vascular accident (resulting in brain edema from dead brain tissue)​ Ruptured blood vessel in the brain (cerebral hemorrhage)​ Overproduction of cerebral spinal fluid​ Inflammation or infection in the meninges (lining of the brain and spinal cord)​ Past Surgical History​ Brain surgery​ Spinal surgery Social History​ Prolonged anoxia (near drowning)​ Trauma​ Occupational exposure to toxins (lead or arsenic)​

Diagnostic Tests: Altered Intracranial Regulation​ The client that has episodes of altered intracranial regulation will undergo positron emission tomography (PET) scan. What should the nurse instruct the client prior the procedure? Instruct the client to take sedatives. Have a client empty their bladder. Do some activities before the procedure. Have the client shampoo their hair.

Positron emission tomography (PET) scan measures the metabolic activity of the brain to assess cell death or damage. Prior to the procedure, instruct the client not to take any sedatives or tranquilizers. Have the client empty the bladder. Insert intravenous lines. Inform the client that during the procedure, the client will be asked to do different activities. Shampooing the client's hair prior is not applicable to this procedure.

Spinal Cord Injuries The most common causes of spinal cord injury (SCI) are related to trauma, which include falls, motor vehicle collisions (MVC), sports related injuries, and violence. The trauma to the spinal cord affects its ability to transmit and receive messages from the brain to the rest of the body's vital systems that control sensory, motor, and autonomic function below the level of the injury (American Association of Neurological Surgeons, 2020). ​ The damage caused by SCI occurs at one of two phases post injury

Primary Injury Secondary Injury Primary injury, or the direct physical trauma to the spinal cord occurs due to blunt or penetrating trauma. The injury causes the spinal cord to tear, shred, compress, or loss blood supply, affecting function. Secondary Injury Secondary injury, or the aftermath/consequences of the initial insult, which causes further permanent damage. After the original injury, the spinal cord begins to hemorrhage. This causes neurons to be destroyed, the spinal cord to swell, and further compression of the cord occurs. This edema leads to decreased oxygen perfusion and hypoxia. Irreversible nerve damage and permanent neurologic deficit are the end products of secondary SCI injuries. These phases explain why it is incredibly important to provide all clients who are suspected of having an SCI with a rigid cervical collar or brace to immobilize the spine from further damage. While moving the client as a unit, or "log-rolling", any movement that is necessary of the client (e.g., turning, transferring to a stretcher or bed, etc.) needs to be completed with multiple team members. These techniques will decrease the chance of secondary injury occurring.

Priority Assessment: Janet ​ Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity What assessments are priority for the nurse to complete? Select all that apply. Evaluate Janet's orientation level by asking her today's date. Assess Janet's gait by having her walk to the door and back to the bed. Ask Janet if she has any allergies to medications. Tell Emily that she needs to get Janet's advanced directive, or she cannot be treated. Ask when Janet's symptoms first started.

Priority assessments for neurologic clients is important to be done swiftly and thoroughly. Asking about Janet's orientation level (maybe through a Glasgow Coma Scale assessment) is important to understand her baseline neurologic function. Inquiring as to when Janet's symptoms first occurred is important, especially if fibrinolytic therapy is an option for intervention. It is always important to ask about allergies to medications, especially things like contrast dye. It would not be safe to have Janet get out of bed to assess her gait, as she has come to the hospital with right sided weakness. Assessments of motor function can be completed while the client is still in bed- foot push/pulls, grip strength, arm strength, etc. It is also not a requirement for treatment to have an advanced directive. It is ideal to have this documentation in the event of a status change, but is not a requirement.

Meet Jonathan Patient Information Jonathan Bennis ​ 46-year-old male ​ Allergies: none​ Admitting Diagnosis: exacerbation of myasthenia gravis (MG)​ The nurse is completing an admission assessment on Jonathan. What is the priority assessment? Gait​ Ability to swallow Level of consciousness Respiratory effort

Remember that the muscle weakness associated with myasthenia gravis (MG) can impact those that assist with breathing, the nurse's priority assessment for Jonathan is his respiratory effort. Knowing he is admitted with an exacerbation of MG, this may be a concern. The other information is not a priority now.

Warning Signs ​ What are warning signs for a stroke? Select all that apply. Gait disturbances Atrial fibrillation Hyperreflexia Slurred speech Facial drooping

Remember the acronym "BE FAST" when it comes to the warning signs of a stroke! Are there Balance issues? Abnormal Eye movements? Facial droop? Arm weakness? Speech difficulties? A stroke is pending, and Time is critical! Atrial fibrillation is not a warning sign of a stroke, but a risk factor. Hyperreflexia does not occur with strokes.

Generating Solutions Which nursing intervention is priority when working with clients who exhibit mild cognitive impairment? Reminiscence group therapy Reality orientation Behavioral confrontation Reflective communication

Reality orientation is generally helpful to clients who exhibit mild cognitive impairment; these clients are aware of their impairment, and appropriate orientation helps reduce their anxiety. Behavioral confrontation should only be used to address persistent undesirable actions. Reflective communication and reminiscence group therapy are measures to promote contentment and belonging, which are used with clients living with moderate cognitive impairment.

Prevention Measures ​ The nurse discusses ways to prevent a stroke with a client. What measures should the nurse include in teaching? Select all that apply. Encourage the use of seatbelts in vehicles Proper treatment for hypertension Avoid the use of recreational drugs Keep serum cholesterol levels under control Treat atherosclerosis appropriately

Remember that hypertension is one of the biggest risk factors and causes of both ischemic and hemorrhagic strokes, so proper treatment and intervention is imperative. Keeping serum cholesterol levels low and treating heart disease is also important to help decrease the chance of stroke. Recreational drugs, like cocaine, can cause significant hypertension for clients, and increase the fragility of vessels. While encouraging seatbelts is always a good educational point, it is not directly linked to decreasing the risk of a stroke.

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 2 / 6 Which intervention can be delegated appropriately to which team member by the nurse? Some team members may be utilized more than once. ​ Registered Nurse (RN) Licensed Practical ​ Nurse (LPN) Unlicensed Assistive Personnel (UAP ) Assist George to the commode Document George's intake and output​ Evaluate George's response to the first dose of levodopa Administer oral acetaminophen for fever Provide discharge teaching to George

Remember the main point of delegation: Is the task that is being delegated safe for this person to do? Is it within their scope of practice?​ The registered nurse (RN) can complete all tasks discussed. The licensed practical nurse (LPN) cannot evaluate a response to a first dose of medication for a client, nor can they provide any education to the client. However, they are able to reinforce educational material that has been already discussed. ​ The unlicensed assistive personnel (UAP) can assist with George's care by helping him to the bedside commode and documenting his intake and output in the medical record.

Causes Which concerns are risk factors for the development of Alzheimer's disease (AD)? Select all that apply​. High calcium level Family history Past head injuries Sedentary lifestyle Age

Risk factors for Alzheimer's disease (AD) include ​ increasing age female gender​ family history of AD​ though the exact link is not known, those with Down syndrome often experience AD in their 30s and 40s head injury. Some studies have shown a link between AD and a major head injury high cholesterol and hypertension may also increase the risk of AD

Nursing Process The client had a positive Romberg test. What is the priority nursing diagnosis? Powerlessness Risk for fall Impaired breathing pattern Decreased cardiac output

Romberg test assesses balance. Therefore, if a client is positive Romberg test, this means that the client does not have good balance and is at higher risk for falls.

Seizure Phase The nurse is providing education to a client newly diagnosed with seizures to recognize the aural phase of seizure activity. What information would the nurse provide? A hallucination that occurs while the client is seizing​ A sensory warning that occurs just before seizure activity The period of relaxation and tiredness after the seizure activity is over A state of amnesia after the seizure activity

The aural phase of seizure activity is characterized by a sensory warning that comes before a seizure. It is similar each time it occurs, so the clients may be able to identify that seizure activity is incoming.

Nursing Management: Altered Intracranial Regulation​ A client who has ischemic stroke is confused and very anxious. Which nursing action will be included in the plan of care? Encourage the significant other to remain at bedside. Apply two-point restraint to avoid self-injury. Turn all the lights in the room on. Provide a stimulating environment.

The best nursing intervention to a client that is confused and very anxious is to encourage the significant other to remain at bedside. This will help to alleviate the client's anxiety and continually address any confusion by having someone familiar to the client.

Communicating With Family The client recently admitted to the emergency department (ED) has family at the bedside. The spouse and teenage children are asking many questions about treatment. Which action of the following taken by the nurse is best? Allow the family to stay with the client and briefly explain the interventions to them. Call social services to talk to the family about their loved one's admission. Refer the family to chaplain services to deal with their anxiety. Ask the family to stay in the waiting room.

The client's family is in an unfamiliar environment and may be very anxious of the client's health condition. It is the nurse's responsibility to not only care for the client, but also their loved ones. If the client's family is not impeding care, it is important to allow them to stay at the bedside and briefly (and simply) explain the interventions being performed. It would only be appropriate to ask the family to go to the waiting room if it interfered with care. Remember that this is a time of great anxiety for them, and if there are ways the healthcare team can provide therapeutic and compassionate care for the family, it will also improve the outcomes for the client

Recognizing Cues An older adult has been brought to the clinic by family because the client has become increasingly confused over the past week. Which questions should the nurse ask to assess the client's orientation? Select all that apply. "What does a stitch in time saves nine mean?" "What is your name?" "Who is that woman sitting next to you?" "In which state were you born?" "What time is it?" "What did you have for breakfast this morning?" "Can you tell me where we are right now?"

The cognitive assessment related to orientation includes assessing the client's knowledge of person (name), place (where they are right now), and time (asking the time). The other questions relate to short- and long-term memory (breakfast and birthplace, respectively), ability to identify others (family member who brought them for care), and ability to reason or problem-solving (explain a proverb or statement).

Clinical Manifestations Which assessment findings should cause the nurse to complete a focused assessment for additional clinical manifestations of Parkinson's disease (PD) in a new client?​​ Select that all apply. Muscle rigidity Hallucinations Decreased urine output Tremors at rest​ Bradykinesia

The common manifestations for Parkinson's disease (PD) are tremors at rest, muscle rigidity, and bradykinesia. These movements have to do with the neurotransmitter imbalance that occurs with the disease. Hallucinations and decreased urine output are not common manifestations of PD. ​

Caregiver Strain George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ While George is resting in bed, the nurse notices that Sharon is in the corner of the room upset. Sharon says tearfully, "I just do not know how I can take care of George by myself now with his new diagnosis. I am so scared he will get hurt." Which of the following will be the best action by the nurse? Encourage Sharon to discuss her feelings with her family for their opinions​ Bring up possible long term facility placement for George after discharge Allow Sharon to cry and express her fears Call pastoral care to the bedside to counsel Sharon

The diagnosis of Parkinson's disease is not only a life-changing event for George, but also for his family. Sharon needs comfort and emotional support at this time, and a safe place to cry and express her fears. The nurse should be honest and provide a therapeutic environment. ​ Calling pastoral care, telling Sharon to discuss her feelings with family, or discussing long term facility placement for George are all examples of not addressing Sharon's immediate feelings and needs. They are not the appropriate interventions at this time.

Diagnostic Tests: Altered Intracranial Regulation​ The client is schedule to have electroencephalography. What should the nurse instruct the client prior the procedure? Wash the hair paste out of hair after the procedure. This procedure is invasive and needs consent. Withhold some medications like anti-seizure medication. Assess for any iodine or shellfish allergies.

The electroencephalography evaluates any presence of brain activity. Inform the client that the procedure is noninvasive. Determine if any medications need to be withheld such as tranquilizer or anti-seizure. After the procedure, resume the medications and wash the paste out of hair. Assessing iodine or shellfish allergies is important but not directly related to the procedure.

Medication Options A nurse is caring for a client with Parkinson's disease (PD). Which class of medications does the nurse anticipate administering to the client? Dopaminergic​ Cholinergic Monoamine oxidase inhibitor (MAOI)​ Beta blocker​

The goal of this drug therapy is to correct the neurotransmitter imbalance that is associated with the development of PD. This is achieved by using dopaminergic medications, that increase the effectiveness of dopamine, an important neurotransmitter that is part of the imbalance associated with PD.

Causes of Spinal Cord Injuries What are the common causes of spinal cord injuries (SCI)? Select all that apply.​ Violence Motor vehicle collisions​ Hypertension Falls​ Cancer Sports-related injuries

The most common causes of spinal cord injuries (SCI) are related to trauma. Falls, violence, sports-related accidents, and motor vehicle collisions (MVCs) are included in this. Hypertension and cancer are not associated with common causes for SCI. ​

Nursing Priority A client with Parkinson's disease (PD) uses a​ walker, speaks in a slurred manner with poor​ articulation, and requires a modified diet. The client recently moved in with their daughter who oversees their care and provides encouragement. Based on client statements, which priority problem should the nurse address first​? "I really enjoy the food and company at meals. I am more relaxed and eat healthier than I did when living by myself." "My grandchildren put away all the throw rugs and are doing a good job of keeping their things off the floor in the main parts of the house." "It has been a challenge communicating with the grandkids, like we speak a different language. They are patient with me, and encourage me to talk, though." "I catch my daughter looking at me angrily​ sometimes, but she​ doesn't say​ anything." ​

The most concerning statement is related to the client's daughter "looking at me angrily." This may indicate that she, as the primary caregiver, is experiencing stress with the additional responsibilities of caring for her father. ​ The client's other statements indicate that the entire family is making changes to keep the client safe (keeping the floors obstacle free to accommodate his walker), being patient (with communication), and providing socialization during meals to promote adequate nutrition — not to mention good food!

Priorities The nurse is going to assess a newly admitted client. Upon arrival to the room, the nurse notices that the client's muscles begin to tense, and their extremities begin to jerk around violently. ​ Place the steps the nurse should take to provide safety to the seizing client in order of highest to lowest priority. ​ Observe the time the activity started. Loosen any restrictive clothing or gown. ​ Document the seizure activity in the medical record. Turn the client to the side and tilt their head forward. ​

The most important step to take first when a client is seizing is to maintain their airway, which can be accomplished by turning the clint to their side and tilting their head forward. Never leave the client who is seizing. Loosening any restrictive clothing or gown is also important to help maintain a patent airway. Observe the time the seizure activity started, and watch how the client responds in each phase. After the seizure activity is completed, it is important to document the specific activity the client had while seizing in the medical record.

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 4 / 6 Now that George is being discharged, his wife Sharon asks how to better keep him safe at home with his new diagnosis. Which recommendation is most appropriate for the nurse to give? Move furniture so there is plenty of space to walk and move around Add more area rugs for stability and comfort when walking Do not allow George into the kitchen alone Remind George to wear slip-on shoes in the house

The nurse should recommend Sharon to rearrange the furniture so that there is ample space for George to move around at home. He should feel independent enough to continue his activities and autonomy after discharge (including going into the kitchen) and providing him with a safe place to move about will help. Area rugs and carpeting is associated with increased fall risk, so this is not advised. Slip-on shoes are not ideal for the Parkinson's disease (PD) client as they do not provide stability when walking, especially with the associated shuffling gait that comes with PD.

Discharge Teaching ​ A 33-year-old client is being discharged after being admitted for seizure activity. Which statements made by the client require the nurse to provide additional teaching? Select all that apply. "I will make sure my wife knows to put a tongue depressor in my mouth to protect my tongue and teeth if I start seizing." "If I stop drinking so much, my seizures may go away."​ "I understand that I will need to be monitored while on my new medications."​ "If I start seizing, I will be safer if someone holds me down."​ "I can order a medical alert bracelet that says I suffer from seizures."​

The priority for a client who is seizing centers around safety. Two rules of seizure safety are to never restrain or hold down a client who is seizing, or place anything in their mouth. We want to turn the client on their side to assist in their ability to get rid of any secretions and maintain an airway. The other information from discharge education is correct.

Priorities of Care: Spinal Cord Injury A new client arrives to the emergency department with a potential high cervical spinal cord injury (SCI). In which order will the nurse perform the following actions? Immobilize the client's head, neck, and spine.​ Prepare to transfer the client for computed tomography (CT) scan. ​ Administer oxygen via nonrebreather mask.​ Assess the client's blood pressure and heart rate. ​

The priority intervention during any admission for who is suspected to have suffered a spinal cord injury (SCI) is to immediately immobilize their head, neck, and spine. This can be completed with a rigid cervical collar (see picture on the left). The next concern is the client's airway, so administering oxygen via non-rebreather mask is most appropriate. Monitoring the client's blood pressure and heart rate are interventions that can be completed next, followed by preparing to transfer the client for a computed tomography (CT) scan. ​

Sundowning Which statement best describes "sundowning"? Being unable to remain awake after the sun sets A normal symptom of the aging adult​ A specific type of agitation found in dementia clients​ A manifestation of delirium

The term "sundowning" refers to a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as agitation, confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering.​ Sundowning is not present in normal aging or delirium, but is associated with hyperactive behavior that begins as the sun sets and often lasts until the next sunrise.​

Medications for Delirium Patient Information Lorena Lorena, a 76-year-old former elementary school teacher, is brought to the healthcare provider's office by her daughter, Elizabeth. Lorena has recently had some increasing decline in her memory and inability to perform activities of daily living (ADLs) independently. Lorena currently lives at home alone. Elizabeth asks the nurse, "Mom has been more confused over the last couple of days, to the point where she gets agitated for hours at a time and does not sleep. My sister and I are staying with her 24 hours a day, and we are all exhausted. Should we be doing something different for her?" Understanding that Lorena's condition is consistent with delirium, which response by the nurse is most appropriate? "Alzheimer's disease is progressive, so there is nothing that will make her better." "A prescription for memantine may help reverse the damage in your mother's brain." "An antipsychotic drug will be very helpful when your mother gets agitated."​ "Adding an antidepressant to your mother's medication schedule may help her sleep better."

The use of the antidepressant trazodone may improve sleep in clients with Alzheimer's disease. The use of antipsychotic medications in older clients with dementia is associated with an increased risk for death and should be used only as a last resort (Harding et al., 2020, p. 1392). Memantine cannot reverse the damage already caused by Alzheimer's disease. While Alzheimer's disease is progressive, interventions are available to calm the client, promote their safety, and distract them from their agitated behaviors. ​

Medication Education: Janet ​ Janet Singer​ 67-year-old female​ Allergies: None​ Past Medical History: Diabetes mellitus type 2, asthma, atrial fibrillation, obesity After returning from a computerized tomography (CT) scan, Janet has been diagnosed with an ischemic stroke. She meets the administration criteria for tissue plasminogen activator (tPA). Her daughter Emily asks about the purpose of tPA. What is the best response from the nurse? "tPA will prevent any further clots from forming in your mother's brain." "tPA will break up the clot that is blocking blood from getting to your mother's brain." "tPA will stop any complications from happening after your mother's stroke." "tPA is an investigational medication to stop bleeding with a hemorrhagic stroke."

Tissue plasminogen activator (tPA) is part of fibrinolytic therapy. It activates plasminogen to convert to plasmin, the main enzyme that breaks down clots. tPA only breaks down clots that are already formed, it does not prevent clots from forming in the future, nor does it stop any complications from happening. tPA is not an investigational medication to stop bleeding. Unfortunately, major complications can arise with the administration of tPA, like a hemorrhagic stroke, so close monitoring after administration is incredibly important.

Cranial Nerve Assessment​ How should the nurse assess the client's cranial nerve V (trigeminal)? Ask the client to say "ah" and observe the upward movement of the soft palate. Ask the client to open mouth against resistance. Ask the client to shrug shoulders against resistance. Ask the client to smile, raise eyebrows, and puff out cheeks.

To assess cranial nerve V, ask the client to open mouth against resistance. To assess cranial VII, ask the client to smile, raise eyebrows, and puff out cheeks. To assess cranial nerve IX, ask the client to say "ah" and observe the upward movement of the soft palate. To assess cranial nerve XI, ask the client to shrug shoulders against resistance.

Nursing Management: Altered Intracranial Regulation​ The client is admitted due to head injury, and experiencing cerebral edema. What is the most appropriate nursing action to stabilize the client? Raise the client's head of the bed to 30 degrees. Administer paralytic agents to paralyze the client. Position the patient supine. Suction the client as frequently as possible.

To stabilize the client, raise the client's head of the bed to 30 degrees. This reduces cerebral edema by using gravity to drain fluid from the brain. Suctioning the client frequently will increase intracranial pressure. Administering paralytic agents are not needed unless the client is intubated. Positioning the client supine may make the edema worse.

Hemorrhagic Stroke ​ Which statement about a hemorrhagic stroke is correct? A common cause of hemorrhagic stroke is atrial fibrillation. Prognosis is usually poor for clients who suffer a hemorrhagic stroke. Hemorrhagic strokes are caused by blood clots blocking perfusion to the brain. Fibrinolytic therapy is a common method of treatment for hemorrhagic strokes.

Unfortunately, prognosis with clients suffering from a hemorrhagic stroke is poor. This is because the bleed is usually arterial in origin, which can be catastrophic quickly. The other statements are associated with ischemic strokes.

Evaluating Outcomes The nurse is caring for an elderly client with early dementia. Which outcome below is most realistic and appropriate for this client? The client will be admitted to a nursing home for safety and to have all care needs met. The client will function at the highest level of independence possible. The client will perform all activities of daily living and self-care within a 60-to-90-minute period daily. The client will rest as the nursing staff will perform all self-care activities for the client during their hospital stay.

While a client's safety is of the utmost importance, their independence and quality of life is just as significant. A client with altered cognition and dementia should remain and function at the highest level of independence as possible, for as long as they can. Requiring time limits on care activities increases the likelihood of the client getting frustrated or hurt by going too quickly. Understanding limitations is key. The nursing staff performing all self-care activities for the client is inappropriate as it does not encourage autonomy or participation from the client in their own care.

Parkinson's Disease George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 1 / 6 After his assessment, George asks the nurse, "I have a grandson who is 21. Do I need to tell him to get tested for Parkinson's disease? Will he develop this?" Which of the following is the best response provided by the nurse?​ "While there is a genetic link to Parkinson's disease, there is no guarantee that your grandson will develop the disease." "Your grandson should be evaluated for Parkinson's disease by the time he is 30 years old." "There is no connection between Parkinson's disease and family history."​ "If your grandson smokes cigarettes, he is at a higher risk to develop Parkinson's disease."

While it is important for George's grandson to understand that his grandfather has Parkinson's disease (PD), there is no guarantee he will develop it himself. Although it is not officially classified as a hereditary condition, about 15% of all clients with PD have it in their family history. Research shows us that this disease is more closely related to the inefficient dopamine production in the brain that can impact anyone. Cigarette smoking is not a risk factor for the development of PD.

Plan of Care​ for Eliza Patient Information Eliza Grady ​ 56-year-old female ​ Allergies: Latex​ Past Medical History: Huntington's disease, asthma, anxiety What are important interventions for the nurse to include when caring for Eliza? Select that all apply. Provide opportunities to express fears and needs. Address questions about advanced directives and living wills. Educate on lifestyle changes that delay disease progression.​ Provide information about genetic testing for Eliza's children to determine their own Huntington's disease (HD) risks.​ Prophylactic antibiotics to decrease risk of Eliza developing aspiration pneumonia.

With Huntington's disease (HD) moving in a fatally progressive process, it is important to discuss end of life care and wishes throughout the progression of the disease, including addressing questions about advanced directives and living wills. Providing a safe and therapeutic place for Eliza to express her fears and concerns is imperative to the nurse-client relationship, and to allow for Eliza to express her needs. Remembering that HD is a genetically linked disease, it is important for Eliza's children to understand their options for genetic testing and counseling and to understand their risks associated with development of symptoms, or if they are a carrier of the disease. ​ Prophylactic antibiotics will not decrease the risk of aspiration pneumonia, and there are no lifestyle changes that will delay HD progression. ​

Seizure Disorder Seizure disorder, commonly referred to as epilepsy, is the fourth most common chronic neurologic disorder (with migraine, strokes, and Alzheimer's disease occurring more often). 3.4 million Americans suffer from seizure disorder (Holland, 2019). ​ The seizure itself is an uncontrolled electrical discharge of neurons within the brain that interrupt normal brain function. Seizures can be a manifestation of many types of disorders (like metabolic issues such as electrolyte imbalances, acidosis, or alcohol withdrawal), or they may occur without any apparent cause. ​ Depending on the type of seizure, it may occur in four phases: ​

a

Pharmacology and Intracranial Regulation​ Drag and drop the class for each medication and the action it uses to improve intracranial regulation. ​ Class Action for Intracranial Regulation​ mannitol methylprednisolone morphine sulfate ​ ceftriaxone ​ lorazepam ​ acetaminophen

b

Nursing Diagnosis​ George, a 72-year-old former engineer, is at the healthcare professional's office for a yearly check-up with his wife Sharon. George has new onset complains about hand tremors at rest. Sharon also mentions to the healthcare provider that George's affect seems slower, and his movements less purposeful. ​ Question 2 / 2 Which nursing diagnosis should the nurse select as the priority for George? Imbalanced nutrition: less than the body requires Impaired verbal communication Impaired swallowing​ Caregiver role strain

emember that clients with Parkinson's disease are at an increased risk for aspiration, which would be the priority nursing diagnosis for George at this time. Airway is our top concern.​ While impaired verbal communication, caregiver role strain, and imbalanced nutrition may be appropriate for George's plan of care at some point during his disease progression, they are not the priority at this time.

Seizure Activity Arrange the phases of seizure activity in order. ​ Ictal phase Aural phase​ Postictal phase Prodromal phase

hases of Seizure Prodromal Phase​: A sensation or behavioral change of the client that precedes the seizure by hours or days​ Aural Phase​: The sensory warning that comes before a seizure. It is similar each time it occurs​ Ictal Phase​: The seizure activity Postictal Phase: Recovery period after the seizure activity ​

Cerebral Perfusion Pressure What is the cerebral perfusion pressure of a client that has a blood pressure of 180/90 mm Hg and an intracranial pressure of 35 mm Hg? 85 mm Hg 95 mm Hg 105 mm Hg 110 mm Hg

o calculate the cerebral perfusion pressure (CPP), the formula that will be used is mean arterial pressure (MAP) - intracranial pressure (ICP). The MAP of 180/90 mm Hg needs to be calculated first, and the ICP is 35 mm Hg. Use the formula: (SBP + 2 x DBP) / 3. MAP= [180 + 2 x (90)] / 3 mm Hg MAP= 120 mm Hg Once, MAP is calculated, then CPP can be calculated next. CPP=120 mm Hg - 35 mm Hg CPP= 85 mm Hg

Differentiation In the table below, select the correct disease from the drop-down menu (in the first column) to match the description of the disease process (in the second column). DiseaseDescription of the Disease ProcessHuntington's DiseaseMultiple SclerosisMyasthenia GravisDemyelination of nerve fibersHuntington's DiseaseMultiple SclerosisMyasthenia GravisSkeletal muscle weakness that worsens with useHuntington's DiseaseMultiple SclerosisMyasthenia GravisGenetic disease with excessive amounts of dopamine in the brainHuntington's DiseaseMultiple SclerosisMyasthenia GravisOnset usually slow and gradual, with visual disturbances commonly the first manifestationHuntington's DiseaseMultiple SclerosisMyasthenia GravisTreated with anticholinesterase agents to enhance transmission at neuromuscular junctionHuntington's DiseaseMultiple SclerosisMyasthenia GravisLinked to an excess of dopamine and a deficiency of acetylcholine.

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