Chapter 44 (Lyndel)
A patient complains of periods of confusion and forgetfulness at times, and reports clear thought process at most times of the day. The symptoms have been gradually worsening. What should the nurse say in response to this patient? 1. "Have you started any new medications since the symptoms began?" 2. "You probably have nothing to worry about; it's most likely stress-related." 3. "Everybody has a few problems with memory as they get older." 4. "You should probably have an MRI of your brain."
1. "Have you started any new medications since the symptoms began?" Reason: The diagnosis of Alzheimer disease requires the documented presence of dementia, onset between 40 and 90 years, no loss of consciousness, and absence of systemic or brain disorders that could cause mental changes. Side effects of medication should also be ruled out as a possible cause of the symptoms. A nurse should never discount the patient's concerns and memory loss with confusion, and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.
An adult patient with Bell palsy asks if the facial paralysis and distortion will go away. How should the nurse response to this patient? 1. "Most people recover completely within a few weeks to a few months." 2. "Everyone recovers from Bell palsy in three to five weeks." 3. "Most people have permanent facial paralysis on both sides of the face." 4. "Most people have permanent facial paralysis on one side of the face."
1. "Most people recover completely within a few weeks to a few months." Reason: About 80% of people recover completely from Bell palsy within a few weeks to a few months. Recovery can take longer than 3 to 5 weeks. The facial paralysis will resolve. There will not be permanent paralysis on one or both sides of the face.
A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis (MS). What should the nurse identify as a priority for self-care? 1. Apply for nursing positions that are less stressful and demanding. 2. Work as hard as possible now because it may not be possible later. 3. Continue to work as scheduled without making changes. 4. Leave employment as a nurse due to the need for complete bed rest.
1. Apply for nursing positions that are less stressful and demanding. Reason: Multiple sclerosis (MS) is progressive and will be negatively affected by working long hours and enduring stressful shifts. It is important for this patient to plan a schedule that is less demanding and move now to a work environment that is less stressful for adapting to life with MS. There is no way of knowing how the disease will progress. Maintaining a routine schedule might be difficult because of fatigue. There is no reason for the nurse to quit working because complete bed rest is not indicated.
A patient with stage 2 Alzheimer disease becomes very agitated in the evenings. What would be an appropriate nursing intervention for the nurse to use for this patient? 1. playing soft music in the patient's room 2. use of anti-anxiety medications or tranquilizers 3. moving the patient to an area of activity to provide distraction 4. recommending the patient be moved to a more secure environment
1. Playing soft music in the patient's room Reason: The use of music is considered an alternative therapy helpful in the treatment of Alzheimer disease. Though the use of anti-anxiety agents and tranquilizers might be helpful, this is not a true nursing intervention. Patients with Alzheimer disease should be removed from situations that are causing increased anxiety, such as noisy activities involving large groups. High-stimulus situations may increase anxious feelings and agitation. If the patient were not a danger to him- or herself or others, there would be no indication that a more secure environment would be the best intervention.
A patient comes to the clinic with complaints of blurred vision and muscle spasms that come and go, which have been occurring over the past several months. The patient is scheduled for an MRI and lumbar puncture with examination of the CSF. Which important patient history information is important for the nurse to note? Standard Text: Select all that apply. 1. The patient is a 22-year-old woman from Canada. 2. The patient is Caucasian and lives in the United States. 3. The patient has a family history of epilepsy. 4. The patient has been depressed. 5. The patient's father had Parkinson disease.
1. The patient is a 22-year-old woman from Canada 2. The patient is Caucasian and lives in the United States Reason: Women are affected by MS two times more often than men. Onset is typically between the ages of 20 and 40. High rates of multiple sclerosis occur in regions of northern Europe, the United States, and Canada. Family history of epilepsy, Parkinson disease, and depression are important items of the patient's history but do not support a diagnosis of MS.
The nurse is caring for a patient with Guillain-Barré syndrome. Which medication should the nurse expect to provide to this patient? Standard Text: Select all that apply. 1. antibiotics for urinary tract or respiratory infections 2. morphine for muscle pain 3. anticoagulants to prevent DVTs and pulmonary emboli 4. anticonvulsants to prevent seizures 5. anticholinesterase inhibitors to improve muscle strength
1. antibiotics for urinary tract or respiratory infections 2. morphine for muscle pain 3. anticoagulants to prevent DVTs and pulmonary emboli Reason: Medications may be prescribed to provide support or prophylaxis, or to combat concurrent problems in the patient with Guillain-Barré syndrome. These include antibiotics for urinary tract or respiratory infections, morphine for muscle pain and anticoagulants to prevent DVTs and pulmonary emboli. Anticonvulsants and anticholinesterase inhibitors are not used in the treatment of Guillain-Barré syndrome.
The nurse is completing teaching to a patient with a new diagnosis of Bell palsy. What should be a priority focus of this teaching? 1. eye care 2. promoting effective swallowing 3. pain management 4. improving muscle strength in the upper extremity
1. eye care Reason: Eye care should be addressed since manifestations of Bell palsy include paralysis of the upper eyelid with loss of the corneal reflex and increased tearing on the affected side. Chewing, not swallowing, may be difficult due to unilateral paralysis of facial muscles. Pain may precede the onset of facial paralysis but is not an issue during the course of the disease. Upper extremity muscles are not affected.
The nurse is assessing a patient with Guillain-Barré syndrome. What should the nurse expect to assess in this patient? Standard Text: Select all that apply. 1. increased muscular weakness 2. increased lower extremity edema 3. increased confusion 4. increased intolerance to light 5. decreased deep tendon reflexes
1. increased muscular weakness 5. decreased deep tendon reflexes Reason: As Guillain-Barré develops, the patient will, experience muscle weakness with paralysis from altered nerve conduction (motor nerves become demyelinated). One manifestations of the acute stage is decreased deep tendon reflexes. Increased lower extremity edema, confusion, and intolerance to light are not manifestations of this disorder.
A patient with myasthenia gravis is prescribed pyridostigmine (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report? Standard Text: Select all that apply. 1. increased weakness 2. problems with increased drooling 3. orthostatic hypotension 4. headache 5. increased difficulty swallowing
1. increased weakness 2. problems wiht increased drooling 3. orthostatic hypotension 5. increased difficulty swallowing Reason: An overdose or underdose of anticholinesterase drugs can lead to a myasthenic or cholinergic crisis. The goal of pharmacological therapy is to increase muscle tone; weakness after taking the medication should be reported as soon as possible to offset a medical emergency. Manifestations of myasthenic crisis include increased difficulty swallowing and chewing, muscle weakness, fast heartbeat and restlessness. Increased drooling and lowering of blood pressure should be reported. Headache does not need to be reported.
The nurse is preparing to care for a patient with Alzheimer disease. What should the nurse identify as common signs of this disorder? Standard Text: Select all that apply. 1. poor or decreased judgment 2. declining job skills 3. inability to be comfortable in social situations 4. obsession with organization 5. focused on abstract thoughts
1. poor or decreased judgement 2. declining job skills 3. inability to be comfortable in social situations. Reason: Poor or decreased judgment and having performance issues in social and work settings that are noticeable to others are warning signs of AD. Obsession with organization and a focus on abstract thoughts are not usually associated with Alzheimer disease.
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). The nurse should realize that the prognosis for this patient is: 1. poor; the disease rapidly progresses and is fatal. 2. good; the disease will progress over many years but the quality of life will be good. 3. good; the disease progresses rapidly but can be halted by drug therapy. 4. excellent; the disease will progress slowly and can be controlled by medication.
1. poor; the disease rapidly progresses and is fatal Reason: ALS is rapidly progressive and fatal, characterized by weakness and wasting of muscles that are under voluntary control, without any accompanying sensory changes. The prognosis is not good. The quality of life will not be good. A new drug, riluzole (Rilutek), is now available in the treatment of the disease but will not halt it. Death usually occurs due to respiratory failure.
The nurse is reviewing medication orders for a patient with Alzheimer disease. Which medication should the nurse expect to be prescribed for this patient? 1. rivastigmine tartrate (Exelon) 2. adrenocorticotropic hormone (ACTH) 3. meperidine (Demerol) 4. acetaminophen (Tylenol)
1. rivastigmine tartrate (Exelon) Reason: Rivastigmine tartrate (Exelon) is used to improve the ability to carry out activities of daily living. It decreases agitation and delusions and improves cognitive function. Adrenocorticotropic hormone (ACTH) is a natural hormone, but it has no known ability to treat Alzheimer disease. Meperidine (Demerol) is a narcotic used to treat moderate to severe pain and would not be indicated in treatment of Alzheimer disease. Acetaminophen (Tylenol) is a nonsteroidal anti-inflammatory medication that would not be used routinely to treat Alzheimer disease.
A test that is used to diagnose myasthenia gravis (MG) is ordered by the physician. Because the test involves an injection of a drug that makes muscle strength improve for about five minutes, the nurse realizes that this test most likely is: 1. the Tensilon test. 2. a computed tomography (CT) scan of the legs. 3. a nerve stimulation study. 4. analysis of antiacetylcholine receptor antibodies.
1. the Tensilon test Reason: The Tensilon test produces a five-minute increase in muscle strength. A computed tomography (CT) scan of the legs is not indicated for this patient. The nerve stimulation study and the analysis of antiacetylcholine receptor antibodies are tests that can be done to help diagnose MG, but do not require a drug injection.
A patient comes to the clinic complaining of excruciating pain on one side of the face. What should the nurse suspect is occurring with this patient? 1. trigeminal neuralgia 2. Parkinson disease 3. Bell palsy 4. myasthenia gravis
1. trigeminal neuralgia Reason: Trigeminal neuralgia is characterized by unilateral excruciating facial pain. This symptom is not associated with Parkinson disease, Bell palsy, or myasthenia gravis.
A patient is diagnosed with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the priority nursing activity for this patient? 1. Monitor for infection. 2. Support the patient and family to meet physical and psychosocial needs. 3. Assist the patient to avoid complications. 4. Assist the patient to adapt to the disease.
2. Support the patient and family to meet physical and psychosocial needs. Reason: Support for the patient and family should receive the highest priority for nursing intervention. It is also important to monitor for infection, and assist the patient and family to avoid complications and adapt to the disease, but these are not as important as supporting the patient and family to meet physical and psychosocial needs.
The nurse is assessing a patient with myasthenia gravis. Which are characteristics of this disease? Standard Text: Select all that apply. 1. Routine exercise provides an improvement in muscle strength. 2. Visual problems may be an early symptom. 3. There may be difficulty swallowing. 4. Great improvement occurs in muscle strength with physical therapy. 5. There may be poor articulation in speaking.
2. Visual problems may be an early symptom 3. There may be difficulty swallowing 5. There may be poor articulation in speaking Reason: The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are affected and the patient experiences either diplopia (unilateral or bilateral double vision) or ptosis (drooping of the eyelid). Patients may have periods of dysphagia (difficulty swallowing) and dysarthria (problems with speech). Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles, while rest will improve function. The voice is weak with a muffled nasal quality.
A home health nurse visits a stage 4 Alzheimer disease patient who lives at home with a spouse. In order to meet the needs of the spouse, what should the nurse suggest? 1. making arrangements for the patient to visit the local senior citizens' center in the afternoon 2. finding respite care to come into the home several days a week 3. providing the patient a list of daily activities to complete 4. finding placement in a long-term care facility
2. finding respite care to come into the home several days a week Reason: Stage 4 patients generally exhibit decreased capacity to perform complex tasks (such as buying groceries or paying bills), a reduced memory for personal history, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the patient's care. Since the stage 4 patient does not adapt well to changes in his or her environment, it would be best to have someone come into the home, rather than to have the patient go out.
After returning from a plasmapheresis treatment, the nurse suspects that a patient with myasthenia gravis is demonstrating signs of electrolyte imbalances. What did the patient demonstrate to confirm the nurse's suspicion? Standard Text: Select all that apply. 1. sluggish bowel sounds 2. heart rate 92 and irregular 3. onset of circumoral tingling 4. blood pressure 148/90 mmHg 5. bilateral calf cramping
2. heart rate 92 and irregular 3. onset of circumoral tingling 5. bilateral calf cramping Reason: Observe for circumoral tingling if calcium levels are low and cardiac dysrhythmias and leg cramps if potassium levels are low. Hypocalcemia occurs because the anticoagulant citrate dextrose binds with calcium. Sluggish bowel sounds and elevated blood pressure are not manifestations of electrolyte imbalances.
During an assessment the nurse becomes concerned that a patient is demonstrating early manifestations of amyotrophic lateral sclerosis. What findings did the nurse use to make this clinical determination? Standard Text: Select all that apply. 1. foot drop 2. slurred speech 3. weak hip flexor muscles 4. bilateral weak hand grasps 5. fine muscle fasciculations of the hands
2. slurred speech 4. weak hip flexor musles 5. fine muscles fasciculations of the hands Reason: Muscle twitches or weakness in an extremity and slurred speech are common early manifestations. Fasciculations of involved muscles are common in the early stage of the disorder. With the loss of muscle innervation, the muscles atrophy, and paralysis results. Muscle mass decreases, and patients complain of progressive fatigue. Typically, the disease first affects the hands. Foot drop and weak hip flexor muscles may or may not be a manifestation of amyotrophic lateral sclerosis.
A patient's spouse states, "I've noticed that my spouse doesn't sleep well anymore and sometimes can't find the right words." What is the most appropriate response by the nurse? 1. "These are common changes associated with age." 2. "Does anyone in your family have Alzheimer disease?" 3. "How long have you noticed these changes?" 4. "Do you think your spouse is depressed?"
3. "How long have you noticed these changes?" Reason: Many older adults experience mild problems with memory, but do not have AD. Careful evaluation of the older adult is done in order to avoid misdiagnosing dementia in these cases. Family history is important to note, but a diagnosis of Alzheimer disease is made by eliminating all physiological factors first. Assuming these are age-related changes is inappropriate. Although depression is underdiagnosed in the elderly patient and is sometimes mistaken for Alzheimer disease, a thorough evaluation must be made before making a diagnosis.
The nurse is completing discharge teaching to a patient with a new diagnosis of multiple sclerosis (MS). What does the nurse recommend about diet? 1. Include foods that are easy to swallow since dysphagia is a problem seen in the early stages of the disease. 2. Increase fats and lower carbohydrates. 3. Focus on maintaining a weight as close as possible to what is recommended for the patient's height and weight. 4. Basically remain the same, as there are no nutritional changes in the MS patient.
3. Focus on maintaining a weight as close as possible to what is recommended for the patient's height and weight. Reason: It is recommended that the MS patient should ideally maintain a weight as close as possible to what is recommended for the patient's height and weight. There is no reason for the patient to increase fat intake and decrease carbohydrates. Dysphagia is seen in the later stages of the disease. Dysphagia is a common problem as MS progresses. At that point, the diet should be adapted to accommodate changes in the patient's ability to chew and swallow, and collaboration with a dietitian will be important.
The nurse is reviewing medication orders for a patient with multiple sclerosis (MS). What medication should the nurse expect to be prescribed for this patient? 1. monoamine oxidase (MAO) inhibitors 2. meperidine (Demerol) 3. adrenocorticotropic hormone (ACTH) 4. rivastigmine tartrate (Exelon)
3. adrenocorticotropic hormone (ACTH) Reason: Adrenocorticotropic hormone (ACTH) decreases inflammation and suppresses the immune system. Meperidine (Demerol) is a narcotic analgesic and would not be used to treat MS. MAO inhibitors are used to treat depression. Rivastigmine tartrate (Exelon) is used in the treatment of Alzheimer disease.
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the primary focus of care for this patient? 1. pain management and active range-of-motion (ROM) exercises 2. providing gastrostomy feedings as soon as possible so as to build up muscle mass when motor functions return 3. respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication 4. giving immunosuppressants
3. respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication Reason: Manifestations of ALS include loss of both upper and motor neurons, resulting in loss of the muscles of respiration and swallowing. Atrophy of the tongue and facial muscles results in swallowing difficulty and the inability to communicate. Gastrostomy feedings may be needed as the disorder progresses and muscle function is permanently lost. Pain management and immunosuppressants are not part of the treatment of ALS. Active ROM exercises are instituted only if the patient is able, then passive ROM exercises are initiated to stimulate circulation.
A patient with Guillain-Barré syndrome asks if recovery is possible. What should the nurse respond to this patient? 1. "Recovery is not likely." 2. "Only time and prayer will tell." 3. "Do not worry about that right now." 4. "Recovery will be slow, but your chance of getting better is good."
4. "Recovery will be slow, but your chance of getting better is good." Reason: Recovery is likely, but it can take weeks to years for recovery. Nontherapeutic responses do not address the patient's concerns.
The husband of a patient with Alzheimer disease (AD) asks the nurse to explain sundowning. How should the nurse respond to this question? 1. "The ability to perform simple tasks is lost." 2. "Your wife's eyes will appear more downcast and the lids will droop." 3. "Repetition of words or phrases occurs more frequently." 4. "Your wife can become more agitated, disoriented to time, and wander during the afternoon or early evening."
4. "Your wife can become more agitated, disoriented to time, and wander during the afternoon or early evening." Reason: Sundowning can be decreased by providing quiet activities, such as listening to favorite music in the afternoon or early evening. Downcast eyes and drooping eyelids is not a description of sundowning. Echolalia is the term for frequent repetition of words or phrases. Loss of the ability to perform simple tasks is common to stage 2 of AD.