CHAPTER 64 - Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies

The initial sign of skin pressure is erythema, which normally resolves in less than

1 hour

Which support surface is best for a comatose client who has multiple stage III pressure ulcers over two bony prominences?

Air-fluidized surface

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What should the nurse prepare to administer?

Atropine to control the side effects of edrophonium

A client comes to the clinic for evaluation because of complaints of dizziness and difficulty walking. Further assessment reveals a staggering gait, marked muscle incoordination, and nystagmus. A brain tumor is suspected. Based on the client's assessment findings, the nurse would suspect that the tumor is located in which area of the brain?

Cerebellum

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

Complications

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?

Edrophonium (Tensilon)

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon)

Which is the most common cause of acute encephalitis in the United States?

Herpes Simplex Virus (HSV)

A nurse assesses a patient who has been diagnosed with having a pituitary adenoma that is pressing on the third ventricle. The nurse looks for the associated sign/symptom. What is that sign/symptom?

Increased ICP

Which nutritional deficiency may delay wound healing?

Lack of vitamin C

A client with spinal cord compression from a tumor must undergo diagnostic testing. Which of the following is the most likely procedure for this client?

MRI

The most common cause of cholinergic crisis includes which of the following?

Overmedication

The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's:

ROM

Which nursing intervention is the priority for a client in myasthenic crisis?

Respiratory Effort

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

Rest in an air-conditioned room

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II Pressure Ulcer

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

Stress incontinence

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment?

Substance abuse

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

The patient

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

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?

facial weakness and ptosis will be relieved for approximately 5 minutes