Patients with Neurological Disorders (chpt 46)
A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? "My children are at greater risk to develop this disease." "I need to remain active for as long as possible." "I will lose strength in my arms." "I will have progressive muscle weakness."
"My children are at greater risk to develop this disease." Explanation: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "It must be hard to accept the permanency of your paralysis." "You'll first regain use of your legs and then your arms." "You'll be permanently paralyzed; however, you won't have any sensory loss." "The paralysis caused by this disease is temporary."
"The paralysis caused by this disease is temporary." Explanation: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
The intravenous administration of phenytoin (Dilantin) is used for treating status epilepticus. The recommended dose is 10 to 15 mg/kg to be given at a rate not to exceed 50 mg/min. Therefore, the nurse should give IV Dilantin to a 70 kg adult over: 21 to 30 minutes. 14 to 20 minutes. 28 to 40 minutes. 7 to 10 minutes.
14 to 20 minutes. Explanation: The recommended dosage is 10 to 15 mg/kg. A 70 kg adult would be given 700 mg (10 × 70) to 1,050 mg (70 × 15) at a rate not to exceed 50 mg/min. Infusion would be given over 14 minutes (700/50) to 20 minutes (1,050/50).
Which drug should be available to counteract the effect of edrophonium?
Atropine Explanation: Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.
A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems? Cerebellar abscess Temporal lobe abscess Frontal lobe abscess Wernicke's abscess
Cerebellar abscess Explanation: Indicators of a cerebellar abscess include occipital headache, ataxia, and nystagmus.
Which signs are manifestations of the Cushing triad? Select all that apply. Hypertension Tachycardia Bradycardia Bradypnea
Cushing triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Cardiac function Respiratory function Potential skin breakdown Cognition
Respiratory function Explanation: Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment. Cardiac function and cognition are not normally affected by the disease.
After a seizure, the nurse should place the patient in which of the following positions to prevent complications? Supine, to rest the muscles of the extremities Side-lying, to facilitate drainage of oral secretions Semi-Fowler's, to promote breathing High Fowler's, to prevent aspiration
ide-lying, to facilitate drainage of oral secretions Explanation: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for renal insufficiency. leukopenia and cardiac toxicity. hypoxia. mood changes and fluid and electrolyte alterations.
leukopenia and cardiac toxicity. Explanation: Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lymphoma but is also used to treat secondary progressive MS. Clients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity. Clients receiving corticosteroids are monitored for side effects related to corticosteroids, such as mood changes and fluid and electrolyte alterations
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 70 mm Hg 60 mm Hg 80 mm Hg 50 mm Hg
70 mm Hg Explanation: Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009).
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A disorder in which the body has too many immunoglobulins A disorder in which the body does not have enough immunoglobulins A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" A disorder in which histocompatible cells attack the immunoglobulins
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" Explanation: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.
Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Acetylcholine GABA Dopamine
Acetylcholine Explanation: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.
A client is suspected to have bacterial meningitis. What is the priority nursing intervention? Assess the CSF fluid laboratory test results. Administer prescribed antibiotics. Prepare the client for a CT scan. Encourage oral fluid intake.
Administer prescribed antibiotics. Explanation: A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? Apply an eye patch to the right eye. Administer eye drops as needed. Place needed items on the right side. Exercise the right eye twice a day.
Apply an eye patch to the right eye. Explanation: An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the client. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a client with double vision. Needed items should be placed on the unaffected (left) side.
Which nursing intervention is the priority for a client in myasthenic crisis? Preparing for plasmapheresis Administering intravenous immunoglobin (IVIG) per orders Assessing respiratory effort Ensuring adequate nutritional support
Assessing respiratory effort Explanation: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.
The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? Virus Lymphoma Bacteria Leukemia
Bacteria Explanation: Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? Damage to the vagal nerve Damage to the olfactory nerve Damage to the optic nerve Damage to the facial nerve
Damage to the optic nerve Explanation: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve or the facial nerve.
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? Pupillary asymmetry Irregular breathing pattern Declining level of consciousness (LOC) Involuntary posturing
Declining level of consciousness (LOC) Explanation: With a brain injury such as an epidural hematoma (a likely diagnosis, based on this client's symptoms), the initial sign of increasing ICP is a change in LOC. As neurologic deterioration progresses, manifestations involving pupillary symmetry, breathing patterns, and posturing will occur.
The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply. Demonstrate daily muscle stretching exercises. Have the patient take a hot tub bath to allow muscle relaxation. Allow the patient adequate time to perform exercises Apply warm compresses to the affected areas. Assist with a rigorous exercise program to prevent contractures.
Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Loss of proprioception Patchy blindness Diplopia and ptosis Numbness
Diplopia and ptosis Explanation: The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.
Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter? Serotonin Dopamine Glutamate Acetylcholine
Dopamine Explanation: The impaired balance and uncontrolled tremors of Parkinson's disease have been linked with low levels of dopamine. The other neurotransmitters have not been implicated in Parkinson's disease in this manner.
The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding? Micrographia Dysphagia Hypokinesia Dysphonia
Dysphonia Explanation: Dysphonia (voice impairment or altered voice production) may occur as a result of weakness and incoordination of the muscles responsible for speech.
A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests? X-ray of the brain, bone marrow aspiration, and EEG EEG, blood cultures, and neuroimaging studies Electrocardiography, TEE, prothrombin time (PT), and International Normalized Ratio (INR) Transesophageal echocardiogram (TEE), troponin levels, and a complete blood count
EEG, blood cultures, and neuroimaging studies Explanation: Physicians use EEG and neuroimaging studies to diagnose neurologic problems. Blood cultures can identify infection that can cause seizures. Electrocardiography, TEE, and troponin levels are cardiac-specific diagnostic tests. X-ray of the brain reveals skeletal condition. Bone marrow aspiration isn't indicated for seizure disorder. PT and INR reflect blood coagulation.
A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? Administer Percocet as ordered. Complete a head-to-toe assessment. Administer morning dose of anticonvulsant. Elevate the head of the bed.
Elevate the head of the bed. Explanation: The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF). Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing intracranial pressure (ICP). The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis? Imbalanced nutrition: less than body requirements Risk for unstable blood glucose Risk for deficient fluid volume Excess fluid volume
Excess fluid volume Explanation: A unique clinical feature of St. Louis encephalitis is the development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) with hyponatremia in 25% to 33% of affected patients; SIADH often results in profound fluid overload. Impaired nutrition and unstable blood glucose levels may occur.
Bell's palsy is a paralysis of which of the following cranial nerves? Facial Otic Trigeminal Optic
Facial Explanation: Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve. Trigeminal neuralgia is a paralysis of the trigeminal nerve (cranial nerve V). The optic nerve (cranial nerve II) functions in vision. The vestibulocochlear nerve (cranial nerve VIII) functions in hearing.
During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect? Diplopia Alopecia Gingival hyperplasia Ataxia
Gingival hyperplasia Explanation: Side-effects of dilantin include visual problems, hirsutism, gingival hyperplasia, arrhythmias, dysarthria, and nystagmus.
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? Ask if the client has had a bowel movement. Ask the client if there is pain on ambulation. Ask if the client can walk. Have the client lie on the back and lift the leg, keeping it straight.
Have the client lie on the back and lift the leg, keeping it straight. Explanation: A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? Diplopia that is constant Ptosis that is more pronounced at the end of the day Headache that is worse in the morning Nuchal rigidity
Headache that is worse in the morning Explanation: The most prevailing symptom of a brain abscess is headache, which is usually worse in the early morning. Ptosis and diplopia are seen in clients with myasthenia gravis. Nuchal rigidity is seen in clients with meningitis.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Monro-Kellie hypothesis Cushing response Herniation Autoregulation
Herniation Explanation: With a herniation, the herniated tissue exerts pressure on the brain area into which it has shifted, which interferes with the blood supply in that area. Cessation of cerebral blood flow results in cerebral ischemia, infarction, and brain death. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that because of limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? Motor symptoms Sensory symptoms Impaired consciousness Compound forms
Impaired consciousness Explanation: A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.
A 55-year-old male patient has been admitted to the hospital with a gastrointestinal bleed, and the patient has just experienced a generalized seizure that may be attributable to alcohol withdrawal. When providing immediate care during the patient's seizure, what nursing diagnosis should be prioritized? Acute pain Impaired gas exchange Risk for impaired skin integrity Acute confusion
Impaired gas exchange Explanation: Airway and breathing are priorities in any emergency situation, including seizures. These considerations would be prioritized over confusion, pain, and skin integrity.
The nurse is planning the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. What schedule would be most appropriate for the organization of diagnostic procedures for this patient? In the morning, with frequent rest periods Before bedtime, to promote rest All at one time, to provide a longer rest period Before meals, to stimulate her appetite
In the morning, with frequent rest periods Explanation: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should be avoided at bedtime.
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Infection Increased ICP Exacerbation of uncontrolled hypertension Increase in cerebral perfusion pressure
Increased ICP Explanation: Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first? Administer prescribed antibiotics. Initiate isolation precautions. Apply a cooling blanket. Ensure the family receives prophylaxis antibiotic treatment.
Initiate isolation precautions. Explanation: The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan? Moving the neck from side to side when the collar is off Keeping the head in a neutral position Wearing the cervical collar when sleeping Removing the entire collar when shaving
Keeping the head in a neutral position Explanation: After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise. The front part of the collar is removed for shaving and the neck should be kept still while the collar is open or off.
The diagnosis of multiple sclerosis is based on which test? Magnetic resonance imaging (MRI) Neuropsychological testing Evoked potential studies Cerebrospinal fluid (CSF) electrophoresis
Magnetic resonance imaging (MRI) Explanation: The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed on MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.
The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? Maintenance of a patent airway Positioning to prevent complications Determination of the cause Assessment of pupillary light reflexes
Maintenance of a patent airway Explanation: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway.
A new ancillary staff member is assisting the nurse with a client diagnosed with Parkinson's disease. The client needs assistance with eating but doesn't require thickened liquids to aid swallowing. Which instruction should the nurse give the ancillary staff member about eating assistance? Make sure the client is sitting with the head of bed elevated to 90 degrees. Assist the client into a comfortable position and stay alert for coughing, which signifies aspiration. There are no special precautions for the client with Parkinson's disease. Clients with Parkinson's disease shouldn't have liquids; remove them from the dinner tray before serving food to the client.
Make sure the client is sitting with the head of bed elevated to 90 degrees. Explanation: Clients with Parkinson's disease are at risk for aspiration; therefore, the nurse should instruct the ancillary staff member to make sure the head of the client's bed is elevated to 90 degrees before assisting the client with eating. A client doesn't always cough when he aspirates. A client with Parkinson's disease needs fluids to maintain fluid balance. Aspiration is a great concern with Parkinson's disease; therefore; the staff should take precautions to prevent this complication.
Which is the primary vector of arthropod-borne viral encephalitis in North America? Ticks Mosquitoes Birds Spiders
Mosquitoes Explanation: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Creutzfeldt-Jakob disease Parkinson disease Huntington disease Multiple sclerosis
Multiple sclerosis Explanation: The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of: Parkinson disease. seizure disorder. Huntington disease. multiple sclerosis.
Parkinson disease. Explanation: Although antiparkinson drugs are used in some clients with Huntington disease, these drugs are most commonly used in the medical management of Parkinson disease. The listed medications are not used to treat a seizure disorder. The listed medications are not used to treat MS.
Which diagnostic test is used for early diagnosis of HSV-1 encephalitis? Magnetic resonance imaging (MRI) Polymerase chain reaction (PCR) Lumbar puncture (LP) Electroencephalography (EEG)
Polymerase chain reaction (PCR) Explanation: PCR is the standard test for early diagnosis of HSV-1 encephalitis. An LP often reveals a high opening pressure and low glucose and high protein levels in CSF samples. EEG is used to diagnose seizures. An MRI is used to detect brain lesions.
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Providing for privacy Positioning the patient on his or her side with head flexed forward Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Restraining the patient to avoid self injury
Positioning the patient on his or her side with head flexed forward Providing for privacy Loosening constrictive clothing During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced? Positive Brudzinski sign Positive Kerning sign Photophobia Nuchal rigidity
Positive Brudzinski sign Explanation: A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury), and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.
A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck, and he tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? Hyperactive patellar reflex Sluggish pupil reaction Negative Brudzinski's sign Positive Kernig's sign
Positive Kernig's sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Hyperactive patellar reflex and a sluggish pupil reaction are not common signs of meningitis.
A client comes to the clinic reporting low back pain and muscle spasms. He states, "The pain seems to travel into my hip and down to my leg." A herniated lumbar disk is suspected. Which of the following would help to confirm the suspicion? Select all that apply. Increased pain with bed rest Altered tendon reflexes Muscle weakness Negative straight leg test Postural deformity
Postural deformity Muscle weakness Altered tendon reflexes A herniated lumbar disk manifests with pain aggravated by actions that increase intraspinal fluid pressure, such as bending, lifting, or straining. The problem is relieved by rest. Typically, there is a postural deformity and results of the straight leg test are positive. Muscle weakness, altered tendon reflexes, and sensory loss also are noted.
During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client? Prevention of joint contractures Promotion of critical thinking ability Creation of a positive environment Use of adaptive equipment
Prevention of joint contractures Explanation: A critical intervention during the acute phase of a stroke is to prevent joint contractures to avoid complications later in the client's rehabilitation. Joint contractures are prevented through correct body positioning and by putting affected extremities through a full range of motion four or five times a day. Promoting critical thinking ability and using adaptive equipment are not priorities during the acute phase. Creating a positive environment is helpful in motivating the client, but this is not as high a priority as the prevention of joint contractures.
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? Providing palliative care Initiating isolation procedures Preparing for organ donation Administering amphotericin B
Providing palliative care Explanation: vCJD is a progressive fatal disease; no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? Cognition Respiratory function Cardiac function Potential skin breakdown
Respiratory function Explanation: Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment. Cardiac function and cognition are not normally affected by the disease.
A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? Riluzole Baclofen Dantrolene sodium Diazepam
Riluzole Explanation: Riluzole, a glutamate antagonist, has been shown to prolong survival for persons with ALS for 3 to 6 months.
Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? Seizure was 1 minute in duration including tonic-clonic activity. Sleeping quietly after the seizure Seizure began at 1300 hours. The client cried out before the seizure began.
Seizure was 1 minute in duration including tonic-clonic activity. Explanation: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Semisolid food with thick liquids Solid food with thin liquids Thin liquids only Pureed food with water
Semisolid food with thick liquids Explanation: A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.
The nurse is providing morning care for a male patient who is recovering from a head injury. The patient's right hand has begun twitching, and he is speaking unintelligibly. This patient has most likely experienced what type of seizure? Simple partial Absence seizure Tonic-clonic seizure Complex partial
Simple partial Explanation: In simple partial seizures, only a finger or hand may shake, or the mouth may jerk uncontrollably. The person may talk unintelligibly, may be dizzy, and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness. In complex partial seizures, the person either remains motionless or moves automatically but inappropriately for time and place, or he or she may experience excessive emotions of fear, anger, elation, or irritability. Tonic-clonic seizures begin with rigidity (tonic phase), followed by repetitive clonic activity of all extremities characterized by stiffening or jerking of the body. Absence (petit mal) seizures involve short episodes of staring and loss of awareness.
The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline with carbidopa-levodopa to the medication regime should result in which purpose? Prevents side effects from carbidopa-levodopa Replaces dopamine Slows the progression of the disease Relieves symptoms of dyskinesia
Slows the progression of the disease Explanation: Selegiline increases dopaminergic activity and slows the progression of the disease. Carbidopa-levodopa is a dopamine replacement drug. Anticholinergic drugs are used to reduce the symptoms of dyskinesia and other side effects.
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Padded tongue blade Suction machine with catheters Sphygmomanometer Nasal cannula and oxygen
Suction machine with catheters Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.
A young adult has just been diagnosed with atonic seizures. The nurse practitioner explains to the patient that this type of seizure is characterized by: Jerking movements involving muscles on both sides of the body. Short episodes of staring and loss of awareness. Bilateral muscle movements without loss of consciousness. Sudden loss of muscle tone that results in a fall.
Sudden loss of muscle tone that results in a fall. Explanation: Atonic seizures are characterized by sudden loss of muscle tone, resulting in falls or a "drop" to the ground, with rapid recovery. Clonic seizures are characterized by jerking movements, which involve muscles on both sides of the body. Absence (petit mal) seizures refer to short episodes of staring and loss of awareness. Myoclonic seizures (bilaterally massive epileptic) are characterized by jerking movements of a muscle or muscle group, without loss of consciousness.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates. Tell the patient to smile every 4 hours.
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Electromyogram (EMG) Tensilon test Serum studies Computed tomography (CT) scan
Tensilon test Explanation: Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.
The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? The client grasps the affected arm at the wrist and raises it. The client arranges a community service to deliver meals. The client ambulates with the assistance of one. The client uses a mechanical lift to climb steps.
The client grasps the affected arm at the wrist and raises it. Explanation: The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? The client will verbalize an understanding of feelings that preempt seizure activity. The client will post emergency numbers on the refrigerator for ease of obtaining. The client will take the seizure medication at the same time daily. The client will remain free of injury if a seizure does occur.
The client will remain free of injury if a seizure does occur. Explanation: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following? Medication needs to be adjusted to higher doses. The client is exhibiting signs of medication overdose. The client is having an exacerbation. The disease has entered the late stages.
The disease has entered the late stages. Explanation: In late stages, the disease affects the jaw, tongue, and larynx; speech is slurred; and chewing and swallowing become difficult. Rigidity can lead to contractures. Salivation increases, accompanied by drooling. In a small percentage of clients, the eyes roll upward or downward and stay there involuntarily (oculogyric crises) for several hours or even a few days. Options A, B, and C are therefore incorrect.
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value? The CPP is low. The CPP is high. The CPP reading is inaccurate. The CPP is within normal limits.
The normal CPP is 70 to 100 mm Hg. Therefore, a CPP of 40 mm Hg is low. Changes in intracranial pressure (ICP) are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage.
A patient with Parkinson's disease is experiencing an on-off syndrome. What does the nurse recognize that the patient's clinical symptoms will be? The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication. The patient will have unilateral resting tremors and then will have a period of no tremors present. The patient will have a slow, shuffling gait and then will be able to move at a faster pace. The patient will have a period when medication with levodopa will be unnecessary.
The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication. Explanation: The patient may experience an on-off syndrome in which sudden periods of near immobility ("off effect") are followed by a sudden return of effectiveness of the medication ("on effect"). Changing the drug dosing regimen or switching to other drugs may be helpful in minimizing the on-off syndrome.
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." "It's too early to give a prognosis." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "Don't worry; your child will be fine."
There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." Explanation: The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.
An infusion of phenytoin (Dilantin) has been ordered for a patient whose brain tumor has just caused a seizure. The patient has been receiving D5W at 100 mL/hour to this point and has only one IV access site at this point. How should the nurse prepare to administer this drug to the patient? Saline lock the patient's IV and wait 15 minutes before administering phenytoin. Administer the drug orally due to the risk of precipitation. Mix the phenytoin in a 50 mL mini-bag of D5W. Thoroughly flush the patient's IV with normal saline.
Thoroughly flush the patient's IV with normal saline. Explanation: The rate of Dilantin administration is no faster than 50 mg/min in normal saline solution, since the drug precipitates in D5W. If the preexisting solution contained dextrose, the nurse flushes the IV line with normal saline before administering the medication.
A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mm Hg and the ICP is 18 mm Hg; therefore his cerebral perfusion pressure (CPP) is: 88 mm Hg. 48 mm Hg. 52 mm Hg. 68 mm Hg.
To determine CPP, subtract the ICP from the mean arterial pressure (MAP). The MAP is derived using the following formula using the diastolic pressure (DP) and systolic pressure (SP): MAP = DP + 1/3(SP - DP) In this case MAP = 60 mm Hg + 1/3(90 mm Hg - 60 mm Hg) = 70 mm Hg CPP = MAP - ICP CPP = 70 mm Hg - 18 mm Hg = 52 mm Hg
A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? Maintaining bed rest for 72 hours after the laminectomy Placing the client in semi-Fowler's position Turning the client from side to side, using the logroll technique Keeping a pillow under the client's knees at all times
Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? Uneven, labored respirations Warm, dry skin Urine output of 40 ml/hour Soft, nondistended abdomen
Uneven, labored respirations Explanation: A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by uneven, labored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.
The nurse is caring for a client with Bell's palsy. Which of the following teaching points is a priority in the management of symptoms for this client? Use ophthalmic lubricant and protect the eye. Complete the course of antibiotics as prescribed. Encourage semiannual dental exams. Avoid stimuli that trigger pain.
Use ophthalmic lubricant and protect the eye. Explanation: The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.
The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient? Reorienting the patient to person, time, and place Limiting free water to 1 L per day Maintaining the patient on bed rest Using the incentive spirometer as prescribed
Using the incentive spirometer as prescribed Explanation: Respiratory function can be maximized in GBS with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré does not affect cognitive function or level of consciousness. Fluid restriction is not indicated.
A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? Phenobarbital Vasopressin Furosemide (Lasix) Mannitol
Vasopressin Explanation: Manipulation of the posterior pituitary gland during surgery may produce transient diabetes insipidus of several days' duration (Hickey, 2009). It is treated with vasopressin but occasionally persists.
A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? Carvedilol (Coreg) Verapamil (Calan) Amiodarone (Cordarone) Metoprolol (Lopressor)
Verapamil (Calan) Explanation: Calcium channel blockers, such as verapamil, and beta-adrenergic blockers, such as metoprolol, are commonly used to treat migraines because they help control cerebral blood vessel dilation. Calcium channel blockers, however, are ordered for clients who may not be able to tolerate beta-adrenergic blockers, such as those with asthma. Amiodarone and carvedilol aren't used to treat migraines.
A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect: Acute attacks followed by progression at a variable rate. Progressive disability from onset. Acute attacks with full recovery or residual deficit upon recovery. Progression with clear relapses with or without recovery.
With relapsing-remitting multiple sclerosis, recovery is usually complete with each relapse. Residual deficits may occur and accumulate over time, contributing to a functional decline.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 48 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 72 hours after exposure Within 24 hours after exposure
Within 24 hours after exposure Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at preventing renal insufficiency. maintaining hemodynamic stability and adequate cardiac output. controlling seizures and increased intracranial pressure. preventing muscular atrophy.
controlling seizures and increased intracranial pressure. Explanation: There is no specific medication for arbovirus encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include akathisia and dysphagia. memory and cognitive impairment. diplopia and bradykinesia. sensory disturbance, limb pain, and behavioral changes.
sensory disturbance, limb pain, and behavioral changes. Explanation: Sensory disturbance, limb pain, and behavioral changes are the initial symptoms of vCJD. Memory and cognitive impairment occur late in the course of vCJD. The other symptoms listed may happen in the later stages of vCJD.
The nurse is assessing a male client with multiple sclerosis (MS). What education would the nurse provide to assist the client in managing this disease? Select all that apply. Recommend bone mineral density testing Effective treatment of anemia Participation in occupational therapy Treatment of any episodes of depression Avoidance of hot temperatures
Avoidance of hot temperatures Treatment of any episodes of depression Effective treatment of anemia Participation in occupational therapy Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the central nervous system (CNS). Fatigue affects most people with MS and is often the most disabling symptom. Heat, depression, anemia, deconditioning, and medication may contribute to fatigue. Avoiding high temperatures, effective treatment of depression and anemia, a change in medication, as well as occupational and physical therapy may help manage fatigue. Pain is another common symptom of MS. Bone mineral testing is recommended for women with MS who are perimenopausal. This group of clients are likely to have pain related to osteoporosis.
Which positions is used to help reduce intracranial pressure (ICP)? Keeping the head flat, avoiding the use of a pillow Avoiding flexion of the neck with use of a cervical collar Extreme hip flexion, with the hip supported by pillows Rotating the neck to the far right with neck support
Avoiding flexion of the neck with use of a cervical collar Explanation: Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.
A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario? Betaseron Avonex Copaxone Novantrone
Copaxone Explanation: Copaxone reduces the rate of relapse in the RR course of MS. It decreases the number of plaques noted on MRI and increases the time between relapses. Copaxone is administered subcutaneously daily. It acts by increasing the antigen-specific suppressor T cells. Side effects and injection site reactions are rare. Copaxone is an option for those with an RR course; however, it may take 6 months for evidence of an immune response to appear.
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? Ambenonium (Mytelase) Edrophonium (Tensilon) Pyridostigmine (Mestinon) Carbachol (Carboptic)
Edrophonium (Tensilon) Explanation: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.
Which is the most common cause of acute encephalitis in the United States? Herpes simplex virus St. Louis virus West Nile virus Western equine virus
Herpes simplex virus Explanation: Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? High in protein and low in carbohydrate Restricts protein to 10% of daily caloric intake Low in fat At least 50% carbohydrate
High in protein and low in carbohydrate Explanation: A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? IV diazepam Oral phenytoin IV lidocaine IV phenobarbital
IV diazepam Explanation: Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.
A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela? Cerebrovascular accident (CVA) Hydrocephalus Increased intracranial pressure (ICP) Glioma
Increased intracranial pressure (ICP) Explanation: Increased ICP is a significant risk in patients being treated for meningitis. This infection does not cause brain tumors, hydrocephalus, or CVA.
A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela? Glioma Hydrocephalus Increased intracranial pressure (ICP) Cerebrovascular accident (CVA)
Increased intracranial pressure (ICP) Explanation: Increased ICP is a significant risk in patients being treated for meningitis. This infection does not cause brain tumors, hydrocephalus, or CVA.
he nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Decreased pulse rate, abdominal breathing Decreased pulse rate, respirations of 20 breaths/minute Increased pulse rate, respirations of 16 breaths/minute Increased pulse rate, adventitious breath sounds
Increased pulse rate, adventitious breath sounds Explanation: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Explanation: Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.
Which method is used to help reduce intracranial pressure? Using a cervical collar Keeping the head of bed flat Extreme hip flexion, with the hip supported by pillows Rotating the neck to the far right with neck support
Use of a cervical collar promotes venous drainage and prevents jugular vein distortion, which can increase ICP. Slight elevation of the head is maintained to aid in venous drainage unless otherwise prescribed. Extreme rotation of the neck is avoided because compression or distortion of the jugular veins increases ICP. Extreme hip flexion is avoided because this position causes an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.