Pathophysiology Chapter 34: Disorders Affecting Motor Function

A patient with multiple sclerosis (MS) requires teaching on the effects of the health problem on body functions. Which nursing explanation describes the effects of MS plaque formation and demyelination of brain tissue? a. "Lesions or plaques occur in the white matter of the brain because of inflammation and the body's immune response, causing damage to the myelin sheath outside the nerve and delaying the transmission of nerve impulses in the body." b. "Plaques develop in the brain and cause a risk for motor impairment and seizures." c. "T cells and B cells block the immune response and inhibit the inflammatory process within the myelin sheath of the nerve, resulting in seizures." d. "Plaques in the brain occur because of increased low-density lipoproteins; an increased level impairs the brain's ability to use oxygen."

a. "Lesions or plaques occur in the white matter of the brain because of inflammation and the body's immune response, causing damage to the myelin sheath outside the nerve and delaying the transmission of nerve impulses in the body." In MS, lesions develop at different times and at different locations throughout the central nervous system. They typically occur in periventricular white matter, optic nerve, brainstem, and cerebellum. These lesions, or plaques, vary in size. There is no link between multiple sclerosis and low-density lipoprotein; this occurs in atherosclerosis, which leads to cardiovascular diseases such as myocardial infarction and cerebrovascular accident. Although MS can eventually result in motor impairment, the plaques do not directly cause this; seizures would be attributed to other conditions. T cells, B cells, and macrophages enter the brain and attack myelin. This is a result of an increased immune response and inflammatory process. Both white and gray matter brain atrophy can be seen in early stages of multiple sclerosis (MS), but gray matter atrophy can increase rapidly and is directly related to the individual's cognitive function. Neuroaxonal degeneration and cortical demyelination are the most likely cause of gray matter atrophy in MS.

A 4-year-old child with a history of febrile seizures experiences another seizure. Which question should the nurse ask the patient's parent about the febrile seizure? a. "What was your child's age when the febrile seizure occurred?" b. "Does anyone in your family have a history of seizures after the age of 6?" c. "Did the febrile seizure occur a day after the fever resolved?" d. "Was there any evidence of an infection?"

a. "What was your child's age when the febrile seizure occurred?" Children who experience febrile seizures have a 40% chance of future febrile seizures. Febrile seizures usually occur in children between the ages of 6 months and 5 years, peaking in incidence during the second year of life. Febrile seizures may occur at the time of a fever, or the fever may occur a few hours after the seizure. Family history is an indicator for risk of fever, but it is in children aged 6 months to 5 years. Febrile seizures occur as a result of rapid temperature increase above 102.2°F (39°C) rectal. Febrile seizures occur in children ages 6 months to 5 years. Infants and toddlers have a lower seizure threshold.

The public health nurse notes an increase in new cases of multiple sclerosis (MS) among women who are 20-30 years of age. Which is a significant risk factor for multiple sclerosis in women? a. Altered hormone levels b. Pregnancy c. Increased rate of sunbathing d. More genetic links to the condition

a. Altered hormone levels Hormones are thought to play a role in the higher incidence of multiple sclerosis (MS) in women than in men. The genetic link is not more pronounced in women. Sunbathing is not an attributable risk factor for MS. Other risk factors for MS include the following: Geographic location Viral infections Environmental factors Genetic predisposition

A patient with a history of complex partial seizures is having anti-seizure medication adjusted. Which clinical manifestation is associated with complex partial seizures? a. An aura preceding the seizure b. No loss of awareness or consciousness c. Blank stare and unresponsiveness to the environment d. Continuous seizure activity

a. An aura preceding the seizure Complex partial seizures are usually preceded by an aura, last 30 seconds to 2 minutes, and are followed by several hours of impaired consciousness after the seizure, as well as amnesia. No loss of awareness or consciousness is associated with simple partial seizures. Continuous seizure activity is status epilepticus. A blank stare and unresponsiveness to the environment are seen in absence seizures

The nurse prepares to assess a patient with an early stage of amyotrophic lateral sclerosis (ALS). Which symptom should the nurse expect to find in this patient? a. Increasing difficulty buttoning clothes and tying shoes b. Muscle atrophy and wasting in the extremities c. Confusion regarding person, place, and time d. Difficulty swallowing

a. Increasing difficulty buttoning clothes and tying shoes Upper motor neuron symptoms in ALS include slowness of movement, stiffness, incoordination, hyperreflexia, and spasticity. These symptoms commonly manifest in the hands as poor manual dexterity in such tasks as buttoning clothes and tying shoes. Lower neuron impairment is often demonstrated by tongue weakness that disrupts the oral phase of swallowing or, in later stages, atrophy and muscle wasting. Confusion is not an overt sign; instead, poor insight and an inability to plan without overt dementia may occur, and cognitive impairment may be subtle. Upper motor neuron symptoms that may impair dexterity include: Difficulty buttoning clothes or tying shoes. Poor balance. Slow, stiff gait. Spasms. Lower motor neuron symptoms include: Weakness and muscle atrophy in the extremities. Fasciculations (muscle twitches). Cramps due to involvement of the motor neurons in the anterior horn cells.

The nurse observes a patient waiting to be seen in the community clinic. Which observation indicates the patient is experiencing symptoms of Huntington disease (HD)? a. Involuntary movements b. Foot shuffling c. Closed eyes d. Yawning

a. Involuntary movements The most common movement disorder in HD is chorea, which is a state of excessive spontaneous movements that are irregularly timed, randomly distributed, and abrupt. The other findings are not symptoms of HD.

A middle-aged woman experiences urinary incontinence, occasional vertigo, and new-onset visual disturbances. Which health problem should the nurse suspect is occurring with this patient? a. Multiple sclerosis (MS) b. Amyotrophic lateral sclerosis (ALS) c. Myasthenia gravis (MG) d. Parkinson disease (PD)

a. Multiple sclerosis (MS) The most common initial symptoms of MS are paresthesia, weakness or clumsiness of a leg or hand, and visual disturbances. Other common early symptoms include difficulty with bladder control and vertigo. Early symptoms of ALS include frequent tripping or stumbling and muscle twitching, cramping, stiffness, or weakness affecting only an arm or leg. Manifestations of PD include rigidity without tremor, dementia, and sleep disorders. Clinical manifestations of MG can be subtle, and the typical initial symptoms of fatigue and muscle weakness may be missed.

A patient with amyotrophic lateral sclerosis (ALS) is experiencing dysphagia. Which problem should the nurse identify as the most appropriate for this patient? a. Possible aspiration b. Possible immobility c. Possible difficulty with thought processes d. Possible skin breakdown

a. Possible aspiration Upper motor neuron dysphagia results in slow, uncoordinated contractions of the swallowing muscles, whereas, lower motor neuron dysphagia results in tongue weakness and disrupts the oral phase of swallowing. These symptoms result in poor nutrition and dehydration and possibly choking on or aspiration of food or the patient's own secretions. Altered mobility and the risk of impaired skin integrity occur because of weakness and muscle atrophy. Patients do not experience altered thought processes as a direct result of ALS. Additional Learning The progression of ALS is as follows: Begins with the extremities. As the disease progresses, muscle atrophy and spasticity become severe. Overtime, ALS will make it difficult for the person to walk, speak, swallow, and breathe. Death can occur 3-5 years after symptoms begin.

An older adult patient is diagnosed with stage 1 Parkinson disease (PD). Which symptom should the nurse expect to assess in this patient? a. Tremor of one hand b. Muscle rigidity c. Inability to walk d. Tremors of both hands

a. Tremor of one hand Stage 1 PD usually presents as tremor in one limb. Stage 2 is marked by bilateral symptoms. Stage 3 involves significant slowing of body movements. Stage 4 includes muscle rigidity. Stage 5 includes the inability to walk.

A patient with amyotrophic lateral sclerosis (ALS) avoids monthly medical appointments. Which recommendation should the nurse make to help monitor the progression of ALS and prevent complications associated with respiratory failure? a. "It is important to develop a pattern for screening before the dementia associated with the condition develops." b. "It is important that respiratory function is assessed every 3 months and you are monitored for pneumonia and respiratory failure." c. "A decrease in vital capacity to 50% is associated with respiratory failure and sudden death." d. "A decrease in vital capacity to 20% of predicted value is associated with the development of respiratory symptoms such as pneumonia."

b. "It is important that respiratory function is assessed every 3 months and you are monitored for pneumonia and respiratory failure." Patients with ALS require respiratory evaluation at least every 3 months. This aids staging of disease progression and helps the provider monitor the patient for such complications as pneumonia or respiratory failure. A decrease in vital capacity of 50% of predicted value is associated with the development of pneumonia; a vital capacity of 25-30% of predicted value is associated with respiratory failure and sudden death. Frequent checks are required for respiratory function; dementia is not a concern with this condition.

A patient with a family history of Huntington disease (HD) has monthly health screenings to monitor previously detected brain changes. Which finding should the nurse expect on the brain scan report for this patient? a. Extensive atrophy up to 50% of the brain will develop in the first 3 months. b. Microscopic changes will develop into striatal atrophy. c. Hypertrophy of up to 40% of the brain is common. d. Striatal atrophy will be absent, but the caudate nucleus will remain unchanged.

b. Microscopic changes will develop into striatal atrophy. Gross atrophy occurs in the caudate nucleus and putamen, accompanied by selective neuronal loss and gliosis. It is expected that striatal atrophy will be present and, depending on the grading for HD, the caudate nucleus will flatten out and then become concave. The brain will shrink in volume by 40% in early HD. However, there is no time frame in months for this. Hypotrophy, not hypertrophy, occurs in this condition.

A patient with recent neurologic changes is suspected of having a decreased level of dopamine in the brain. Which disease should the nurse suspect? a. Amyotrophic lateral sclerosis (ALS) b. Parkinson disease (PD) c. Huntington disease (HD) d. Multiple sclerosis (MS)

b. Parkinson disease (PD) PD is marked by progressive depletion of presynaptic dopamine in the basal ganglia, specifically in the substantia nigra and the pathways to the corpus striatum. This results in abnormal nerve-firing patterns that cause increased inhibition of the thalamus and reduced excitatory input to the motor cortex due to the imbalance of dopamine and acetylcholine. MS is a chronic inflammatory disorder resulting in central nervous system dysfunction. HD is an inherited disorder resulting in involuntary movement, dementia, and behavioral changes. ALS causes neurodegeneration of the upper motor neurons found in the corticospinal tract and lower motor neurons found in the anterior horn cells of the spinal cord. Additional Learning The most prominent pathophysiological abnormality associated with PD is the progressive depletion of the presynaptic neurotransmitter dopamine in the basal ganglia, specifically in the substantia nigra (SN) and the pathways to the corpus striatum (caudate and putamen).

A patient with amyotrophic lateral sclerosis (ALS) is experiencing dysphagia. Which problem should the nurse identify as the most appropriate for this patient? a. Possible difficulty with thought processes b. Possible aspiration c. Possible skin breakdown d. Possible immobility

b. Possible aspiration Upper motor neuron dysphagia results in slow, uncoordinated contractions of the swallowing muscles, whereas, lower motor neuron dysphagia results in tongue weakness and disrupts the oral phase of swallowing. These symptoms result in poor nutrition and dehydration and possibly choking on or aspiration of food or the patient's own secretions. Altered mobility and the risk of impaired skin integrity occur because of weakness and muscle atrophy. Patients do not experience altered thought processes as a direct result of ALS. Begins with the extremities. As the disease progresses, muscle atrophy and spasticity become severe. Overtime, ALS will make it difficult for the person to walk, speak, swallow, and breathe. Death can occur 3-5 years after symptoms begin.

A patient who takes valproic acid seeks medical attention for ongoing seizures that cause a loss of consciousness and muscular activity. Which type of seizure should the nurse suspect this patient is experiencing? a. Simple partial b. Tonic-clonic c. Complex partial d. Absence

b. Tonic-clonic A tonic-clonic seizure is the most common type of seizure. Medications used to prevent this type of seizure include valproic acid. A complex partial seizure typically has an aura, lasts 30 seconds to 2 minutes, and results in impaired consciousness for several hours, often with amnesia after the seizure. A simple partial seizure does not result in a loss of consciousness; recurrent muscle contractions or numbness or tingling may occur. An absence seizure results in a brief cessation of all motor activity, a blank stare, and unresponsive to the environment for 5-10 seconds, but it may last up to 30 seconds and cause impaired consciousness.

A patient with recently diagnosed amyotrophic lateral sclerosis (ALS) seeks curative therapy at a foreign clinic. Which statement should the nurse make in response? a. "Out-of-country clinics sometimes work for the treatment of ALS, so it's worth a try. I had a friend who recently was successful in treating cancer with oxidative therapy." b. "There is no cure for ALS; you need to accept that you'll die of this disease and make plans for your future." c. "You have the right to seek therapeutic options for your condition, but it's important to remember that ALS is a chronic condition that will require monitoring for its progression and symptoms." d. "ALS does not progress to end stages in all people. It's important to remember that you may not experience the most severe symptoms associated with the disease."

c. "You have the right to seek therapeutic options for your condition, but it's important to remember that ALS is a chronic condition that will require monitoring for its progression and symptoms." It is important that the patient understands that ALS is a chronic condition and there is an expected clinical path it will take as it progresses. This understanding is important because the patient needs to recognize the symptoms and understand how day-to-day life will be affected. The nurse should not use personal experience or anecdotal evidence to support the patient's decision. Telling the patient the "hard truth" is not supportive of the patient's right to seek other treatment. ALS is a progressive disease and moves through its four stages. Patients with ALS should undergo assessments of respiratory function every 3 months from the time of diagnosis. Pulmonary function testing helps measure the extent of the disease's progression.

Which patient has the most significant risk factor for the development of Parkinson disease (PD)? a. A 23-year-old patient who works with pesticides on a farm b. A 34-year-old patient who smokes and has a high caffeine intake c. A 65-year-old man d. A 50-year-old woman with a high level of urate in the blood

c. A 65-year-old man Age is the most significant risk factor, and there is little difference in incidence between men and women before 60 years of age. After age 60, men are affected 1.5 times more often than women, and this difference becomes greater as the age of onset increases. Cigarette smoking and caffeine intake are inversely related to the risk of PD. Pesticides are also a risk factor, but the patient is 23 years old. Even though high urate levels have been associated with the development of PD, a 50-year-old woman is at lower risk than a man is.

A patient experiencing status epilepticus is intubated. Which prescription should the nurse complete next? a. Administering diazepam b. Inserting an indwelling urinary catheter c. Administering 50% glucose d. Initiating cardiac monitoring

c. Administering 50% glucose The main dangers of status epilepticus are hypoxia, hypoglycemia, hyperthermia, acidosis, and exhaustion. After the airway is managed, glucose should be provided, then followed by antiseizure medication. Cardiac monitoring and urinary catheterization can be done at any time. Establish and maintain airway. Administer 50% glucose. Administer diazepam or lorazepam IV and repeat every 10 minutes until seizure activity stops. Administer antiseizure medications such as phenytoin or fosphenytoin (phenobarbital may also be administered). Use IV general anesthesia with propofol as a last resort if seizure activity does not cease.

An 18-month-old toddler who experienced a seizure at home is treated for a severe respiratory infection and is started on antibiotic therapy. Which type of seizure should the nurse suspect that the toddle experienced? a. Partial (focal) b. Absence c. Febrile d. Tonic-clonic

c. Febrile Children who have one febrile seizure have a 40% chance of experiencing another one. Febrile seizures can occur before the appearance of an illness. The affected child may have a normal temperature before and during the seizure, and the seizure may be the first sign of illness. Because of the child's age and the presentation of the seizure with the proceeding illness a febrile seizure should be suspected. Tonic-clonic seizures are the most common type in adults. In a simple partial (focal) seizure, the patient does not lose consciousness. An absence of seizure manifests as a sudden, brief cessation of motor activity. The patient stares blankly and is unresponsive to the environment for 5-30 seconds. Absence seizures are more common in children.

Which symptoms are associated with the atrophy of gray matter of the brain? a. Limb weakness, spasticity b. Incontinence, urine retention c. Forgetfulness, impaired judgment d. Blurred vision, nystagmus

c. Forgetfulness, impaired judgment Gray matter atrophy can increase rapidly and is directly related to the individual's cognitive function. This may include emotional lability, forgetfulness, apathy, and irritability. White matter is composed of nerve fibers and myelin. Incontinence, urine retention, blurred vision, nystagmus, limb weakness, and spasticity are symptoms of demyelination. Urinary effects include hesitancy, frequency, retention, and reflex bladder emptying. Sensory effects include visual (blurred vision, nystagmus), auditory, and tactile effects. Musculoskeletal effects include fatigue, muscle weakness, ataxic movements, intention tremors, and spasticity. Additional Learning Both white and gray matter brain atrophy can be seen in early stages of multiple sclerosis (MS), but gray matter atrophy can increase rapidly and is directly related to the individual's cognitive function. Neuroaxonal degeneration and cortical demyelination are the most likely cause of gray matter atrophy in MS

A patient takes levodopa for Parkinson disease (PD). Which adverse events are related to this medication? a. Drowsiness and memory loss b. QT-interval prolongation and cardiac dysrhythmias c. Hallucinations and orthostatic hypotension d. Tachycardia and chest pain

c. Hallucinations and orthostatic hypotension Long-term drug therapy for PD is associated with serious adverse effects, which may include confusion, hallucinations, psychosis, orthostatic hypotension, motor fluctuations, and dyskinesia. QT-interval prolongation and tachycardia/chest pain are not associated with levodopa. Confusion is a common symptom, but levodopa is not associated with memory loss.

The nurse assists a patient having a tonic-clonic seizure. Which symptoms should the nurse expect to observe in the postictal period? a. The patient has notable pallor and cyanosis. b. The patient has slowed and shallow respirations. c. The patient is sleepy but can be aroused, and breathing is quiet and relaxed. d. Hyperventilation occurs, the patient's eyes roll back, and frothing at the mouth may be noted.

c. The patient is sleepy but can be aroused, and breathing is quiet and relaxed. The postictal period follows the tonic-clonic phase of a seizure. The patient is often sleepy but can be aroused; the breathing is quiet and relaxed. The patient will regain consciousness but may be confused or disoriented. It is common for the patient to sleep for several hours after the seizure. Hyperventilation, eye rolling, and frothing at the mouth are associated with the clonic phase. Skin pallor and cyanosis are associated with the tonic phase. The patient should not demonstrate respiratory distress or decreased effort in the postictal phase.

A pregnant patient with a history of a seizure disorder stops taking medications because of concern the fetus will be harmed. Which advice should the nurse give to the patient? a. "Contact the healthcare provider immediately." b. "Stay off the medications until in the last trimester of pregnancy." c. "Consider a homeopathic remedy for seizures while pregnant." d. "Continue taking medications because the risks of the medicines are minor compared with the risks of having a tonic-clonic seizure while pregnant."

d. "Continue taking medications because the risks of the medicines are minor compared with the risks of having a tonic-clonic seizure while pregnant." The risk of fetal birth defects associated with anti-seizure medications is minor in comparison to the potential complications associated with a tonic-clonic seizure during pregnancy. Discontinuing medications until the last trimester puts the patient at risk for a seizure. The nurse is required to teach the patient about medications. The healthcare provider does not need to be called at this time. A homeopathic remedy or approach would need to be researched for its efficacy and its effects on the fetus.

A patient with idiopathic Parkinson disease (PD) asks if the problem will affect current children. Which response should the nurse make to this patient? a. "Idiopathic causes are determined after a gene has been activated by a specific environmental stressor." b. "Idiopathic causes of PD are linked to the mutation of several genes." c. "Idiopathic conditions always have a genetic predeterminant or risk factor." d. "Idiopathic conditions are the result of an unknown cause and are not associated with a genetic predisposition to the disease."

d. "Idiopathic conditions are the result of an unknown cause and are not associated with a genetic predisposition to the disease." Ninety percent of cases of PD are idiopathic (the result of an unknown cause); the other 10% have a genetic cause. Both unknown and genetic causes may be linked to specific risk factors for the disease, such as increased age, male sex, and environmental factors. It is unknown whether idiopathic causes have a genetic link. Mutations of the LRRK2, PARK2 and SNCA genes have been linked to PD.

A patient experiencing chorea associated with Huntington disease (HD) asks about medications to treat the movements. Which response should the nurse make to this patient? a. "Antidepressant therapy may be beneficial in reducing chorea symptoms." b. "Clonazepam will help with any hallucinations or psychosis." c. "Levodopa is a helpful adjunct therapy for chorea in its early stages." d. "Tetrabenazine is the only FDA-approved medication for Huntington chorea."

d. "Tetrabenazine is the only FDA-approved medication for Huntington chorea." Chorea symptoms are treated when they cause physical injury or interfere with functions such as work or sleep. Tetrabenazine is the only FDA-approved medication for HD chorea. Antidepressant therapy or antipsychotic therapy is not indicated at this time. Levodopa is given in late stages of HD if the patient presents with parkinsonian features.

A patient reports a parent died of complications of amyotrophic lateral sclerosis (ALS). Which critical risk factors for ALS should the nurse identify for this patient? a. Alcohol intake b Low-fat diet c. Marijuana use d. Age and family history

d. Age and family history Recognized risk factors for ALS include age and family history. ALS is more common in white men and in people 60-69 years of age (although it may occur at younger ages). There is some evidence that cigarette smoking is a risk factor. There is weak and conflicting evidence that heavy metal exposure, repetitive muscle use, and trauma are also connected to the development of ALS. Alcohol, low-fat diet, and marijuana use are not associated with the disorder.

A patient is demonstrating signs of multiple sclerosis (MS). For which diagnostic test should the nurse prepare this patient? a. Electrocardiogram b. Ultrasound c. Electroencephalogram d. MRI with gadolinium contrast

d. MRI with gadolinium contrast MRI with gadolinium contrast is the test of choice to support the diagnosis of MS and can reveal the characteristic lesions of demyelination, or plaque. The other tests are not used to diagnose MS.

A pregnant patient with a family history of Huntington disease (HD) learns the fetus has the gene for the disorder. Which information should the nurse provide to the patient about the disorder? a. Most people survive 25-40 years with the disease. b. The onset of HD typically occurs before the age of 10 years. c. Symptoms appear before 35-44 years of age. d. There is a 50% chance of the child's inheriting the gene mutation that causes the disease.

d. There is a 50% chance of the child's inheriting the gene mutation that causes the disease. It is important to know that the child has a 50% chance of inheriting the gene mutation that causes HD. It is rare for symptoms of the disease to appear before age 10. Onset of the disease is before 35-44 years of age. Most people will survive 10-25 years with the disease. Additional Learning If the woman is already pregnant, a chorionic villus biopsy can be performed at 10-11 weeks, or amniocentesis at 14-18 weeks, to test the fetus for the HD gene.