Chapter 70 (2) - Oncologic or Degenerative Neurologic Disorders

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a. attempt to institute bowel-training activities. b. provide the client with small, frequent feedings. c. obtain an order for intermittent catheterization. d. orient the client to his or her surroundings frequently.

B (The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness. DIF: Application/Applying REF: p. 1919 OBJ: Intervention MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration)

The nurse explains that the pathology of Huntington's disease involves a. a decrease in the neurotransmitter norepinephrine. b. an excess of the neurotransmitter dopamine. c. destruction of white matter in the brain. d. formation of neurofibrillary tangles and plaques.

B (The degeneration of the caudate nucleus leads to a reduction in several neurotransmitters, including gamma-aminobutyric acid, acetylcholine, substance P, and metenkephalin, and their synthetic enzymes. This change leaves relatively higher concentrations of the other neurotransmitters, dopamine and norepinephrine. DIF: Comprehension/Understanding REF: p. 1908 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology)

A client tells the nurse that he is experiencing some leg stiffness when walking and slowness when performing ADLs. Occasionally he has noted slight tremors in his hands at rest. This information leads the nurse to suspect a.amyotrophic lateral sclerosis (ALS). b.Huntington's disease. c.myasthenia gravis (MG). d.Parkinson's disease (PD).

D (Early in PD the client may notice a slight slowing in the ability to perform ADLs. A general feeling of stiffness may be noticed, along with mild, diffuse muscular pain. Tremor is a common early manifestation that usually occurs in one of the upper limbs. DIF: Analysis/Analyzing REF: p. 19 MSC: Physiological Integrity Physiological Adaptation-Pathophysiology)

A nurse is performing an assessment on a client who is suspected of having MG. The complaint made by the client that reflects a manifestation commonly seen in clients with this disease is a."By the end of the day, my eyelids usually are drooping." b."I have a great deal of difficulty getting up after I rest for a while." c."I perspire more then I ever have in the past." d."When I have a cold, I usually have a strong cough with it."

A (The primary feature of MG is increasing weakness with sustained muscle contraction. After a period of rest the muscles regain their strength. Muscle weakness is greatest after exertion or at the end of the day. Ocular manifestations are most common, with ptosis or diplopia occurring in a majority of clients. DIF: Analysis/Analyzing REF: p. 1916 OBJ: Assessment MSC: Physiological Integrity Physiological Adaptation-Pathophysiology)

Important self-care measures a nurse can teach a client with Parkinson's disease in order to prevent contractures and improve mobility include which of the following? (Select all that apply.) a. Bend over with your head over your toes to get out of chairs. b. Exercise first thing in the morning. c. Keep a narrow-based gait. d. Look up when you walk, not down at the floor. e. Use a firm surface, like the floor, for exercising.

A, B, D (Clients with PD need to maintain mobility and prevent contractures. Options a, b, and d are important self-help measures. The client should use a wide-based gait. If it is too hard to get on the floor to exercise, the client should do exercises in bed. DIF: Application/Applying REF: p. 1906 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care)

The nurse cautions clients with ALS and their families to be aware that (Select all that apply) a. activities should be spaced throughout the day. b. clients experience incontinence, an early cause of falling. c. cognition will usually decline late in the disease. d. muscle weakness may cause a risk for injury.

A, D (Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder. DIF: Application/Applying REF: pp. 1918-1919 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention)

A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug? a.Diazepam (Valium) b.Interferon b1b (Betaseron) c.Lioresal (Baclofen) d.Methylprednisolone (Solu-Cortef)

B (Drugs used to treat exacerbations in ambulatory clients include Interferon b1b, Interferon b1a (Avonex), and glatiramer acetate (Copaxone). Diazepam and lioresal could be used to treat spasticity, while steroids are used for acute relapses. DIF: Application/Applying REF: p. 1911 OBJ: Intervention MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions)

Health promotion activities the nurse could suggest to a community group for Huntington's disease include a. Eating foods high in omega-3 fatty acids. b. genetic screening for high-risk individuals. c. limiting exposure to heavy metals. d. taking 400 International Units of vitamin E daily.

B (Huntington's disease is inherited in an autosomal-dominant pattern. Genetic testing is available to families in which a member has Huntington's disease. The availability of the testing has created some ethical conflicts. DIF: Application/Applying REF: p. 1908 OBJ: Intervention MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Health Screening)

A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with a. admission and administration of IV corticosteroids. b. an increased dose of anticholinesterase drugs. c. bolus doses of atropine titrated to effect. d. rest and increased sleep.

B (With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options is used to treat a myasthenic crisis. DIF: Comprehension/Understanding REF: p. 1917 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management)

A client with MS is being taught self-care measures to prevent constipation. The nurse would realize goals for teaching had been met when the client states he/she will avoid a.a high-fiber diet. b.citrus fruits. c.laxatives. d.stool softeners.

C (A high-fiber diet, bulk formers, and stool softeners are useful for maintaining stool consistency. Explain that laxatives and enemas should be avoided because they lead to dependence. DIF: Application/Applying REF: pp. 1911, 1912-1913 OBJ: Evaluation MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care)

A 63-year-old male patient has just been diagnosed with Parkinson's disease. The nurse is teaching the patient and his family about dietary practices related to Parkinson's disease. What risk is a priority for the nurse to address? A) Fluid overload and drooling. B) Aspiration and anorexia. C) Choking and diarrhea. D) Dysphagia and constipation.

D (Eating problems associated with Parkinson's disease include aspiration, choking, constipa-tion, and dysphagia. Option A is incorrect since fluid overload isn't specifically related to Parkinson's disease and, although drooling occurs with Parkinson's disease, it doesn't take priority. Anorexia (option B) and diarrhea (option C) aren't specifically associated with Par-kinson's disease.)

Nursing activities for a client with ALS and family include helping them a. decide on an acceptable level of care early in the course of the disease. b. determine if they want to share the diagnosis to allow genetic testing. c. incorporate nonpharmacologic pain control techniques in the plan of care. d. plan for extensive rehabilitation after exacerbations.

A (Disease management in ALS includes topics such as tube feedings and mechanical ventilation. Planning for an acceptable level of care should begin early in the disease, before a crisis occurs. Of course, decisions should be re-evaluated occasionally as the client's wishes may changes with their experiences with the disease. ALS is not a genetically-acquired disorder. Pain control is usually not an issue in the disease, and as the disease is relentlessly progressive (rather than characterized by remissions and exacerbations), extensive rehabilitation is not utilized. DIF: Application/Applying REF: p. 1919 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-End of Life Care)

To prevent complications caused by a common problem of Huntington's disease, the nurse should a. institute seizure precautions. b. pad wheelchairs and beds. c. start an exercise regimen. d. teach different communication signals.

B (Excessive movements and falling can cause injury in the client with Huntington's disease. Interventions include padding wheelchairs and beds, providing shin guards, and using gait belts for ambulation. Communication does become difficult and alternative forms of communication are appropriate before the client becomes completely demented, but this does not take priority over safety precautions. The client does not need an exercise regimen as the client is already hyperactive, and seizures do not occur. DIF: Analysis/Analyzing REF: p. 1908 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention)

Nursing interventions to support the family caring for a client with Alzheimer's disease include (Select all that apply) a. encouraging emotion-focused coping mechanisms. b. helping the family identify safety concerns and modifying the home. c. showing the family how to deal with behavioral problems. d. teaching the family alternative communication techniques.

B, C, D (Research has shown that interventions that focus on communication techniques, behavioral strategies, and environmental modifications improved the quality of life of the caregivers. Emotion-based coping styles are associated with grieving, worrying, and self-accusation and are not as effective as problem-based coping styles. DIF: Application/Applying REF: p. 1901 OBJ: Intervention MSC: Psychosocial Integrity Coping and Adaptation-Quality of Life)

The nurse would suggest to the family of a client who is in the moderate stages of AD and is being cared for in the home to (Select all that apply) a. assess orientation hourly by hiring a sitter if necessary. b. disable the stove but find ways for the client to participate in meal preparation. c. have the client wear an identification badge. d. move knickknacks to the middle of tables. e. secure the environment with a fence so the client cannot leave the home.

B, C, D, E (To provide for the AD client's safety at home, the nurse could suggest several solutions: moving knickknacks to the middle of tables so the edges can be used for balance, blocking off unsafe areas, disabling stoves, removing rugs and runners, installing grab bars in the bathroom, obtaining bedside commodes and hand-held showers, and securing the environment so the client can wander safely. See the Bridge to Home Health Care feature Safety Solutions for People with Alzheimer's Disease for more ideas. DIF: Analysis/Analyzing REF: p. 1900 OBJ: Intervention MSC: Safe, Effective Care Environment Safety and Infection Control-Home Safety)

The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is a.damage occurs primarily to the dendrites and oligodendrites. b.once damaged, myelin cannot regenerate at all. c.plaques occur anywhere in the white matter of the central nervous system (CNS). d.Schwann cells are destroyed slowly but relentlessly.

C (Although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord. DIF: Comprehension/Understanding REF: p. 1909 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Pathophysiology)

To assist the client with Parkinson's disease to reduce tremor, the nurse suggests that the client a.clasp arms about self and squeeze. b.sleep on the non-tremorous side. c.tightly hold change in the pocket. d.visualize stilling the tremor.

C (Clasping change tightly in the pocket, using both hands to complete tasks, and sleeping on the tremorous side will help lessen the tremor. DIF: Application/Applying REF: pp. 1905, 1906 OBJ: Intervention MSC: Physiological Integrity Physiological Adaptation-Illness Management)

A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? A)Chronic confusion B)Impaired urinary elimination C)Impaired verbal communication D)Bowel incontinence

C (Feedback: Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in patients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.)

The most helpful intervention by the nurse for a client experiencing a parkinsonian crisis would be to a.administer oxygen by nasal catheter. b.give the client IV fluids that contain potassium. c.place the client in a nonstimulating environment. d.provide the client with foods high in calcium.

C (Occasionally, clients with PD experience a parkinsonian crisis as a result of emotional trauma or sudden or inadvertent withdrawal of anti-parkinsonian medication. Severe exacerbation of tremor, rigidity, and bradykinesia, accompanied by acute anxiety, sweating, tachycardia, and hyperpnea occur. The client should be placed in a quiet room with subdued lighting. Medical treatment may include barbiturates in addition to anti-parkinsonian drugs. DIF: Application/Applying REF: p. 1905 OBJ: Intervention MSC: Physiological Integrity Basic Care and Comfort-Rest and Sleep)

The nurse formulates the following nursing diagnosis for a client with MS: Impaired Physical Mobility related to muscle weakness. Useful interventions the nurse could plan include a.encouraging long naps or rest periods. b.encouraging strengthening exercises for affected muscles every 4 hours. c.having the client perform ROM exercises at least two times daily. d.performing all the activities of daily living (ADLs) for the client.

C (Range-of-motion exercises should be performed at least twice daily. DIF: Application/Applying REF: pp. 1912-1913 OBJ: Intervention MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures/Health Alteration)