EVOLVE NEURO TEST BANK

Which statement regarding treatment with interferon indicates that the client understands the nurse's teaching? 1 "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day." 2 "Any reconstituted solution must be discarded in 1 week." 3 "I can continue driving my car as long as I have the stamina." 4 "While taking this medicine I should be able to continue my usual activity."

"I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day."

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? 1 Localized seizures 2 Skin desquamation 3 Hyperactive reflexes 4 Ascending weakness

4 Ascending weakness

What is the immediate nursing intervention for a client experiencing autonomic dysreflexia? 1 Administering an alpha blocker 2 Placing the client in a sitting position 3 Giving nifedipine or nitrate as prescribed 4 Monitoring blood pressure every 15 minutes

2 Placing the client in a sitting position

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3 Monitoring respiratory status

Which cytokine is used to treat multiple sclerosis? 1 βInterferon 2 Interleukin2 3 Erythropoietin 4 Colonystimulating factor

1 βInterferon

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)? 1 Hypertension and bradycardia 2 Flaccid paralysis and numbness 3 Absence of sweating and pyrexia 4 Escalating tachycardia and shock

1 Hypertension and bradycardia

A nurse is caring for a client with Guillain-Barre syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow up on cataract progression

1 Physical therapy

Steroid therapy is prescribed for a client with common signs and symptoms of multiple sclerosis. In response to the steroid therapy, what symptom does the nurse expect to decrease? 1 Emotional lability 2 Muscular contractions 3 Pain in the extremities 4 Episodes of vision loss

4 Episodes of vision loss

A nurse is caring for a client newly diagnosed with Guillain-Barre syndrome. The nurse expects which procedure will be considered as a treatment option? 1 Hemodialysis 2 Plasmapheresis 3 Thrombolytic therapy 4 Immunosuppression therapy

2 Plasmapheresis

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the last several months?"

1 "Have you experienced an infection recently?"

A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? 1 Consider that the client most likely will be able to have reflex penile erections. 2 Arrange for the client to see the healthcare provider because sexual performance is unlikely. 3 Discourage the client from forming sexual relationships because little pleasure will be possible. 4 Reassure the client that he will be able to have sexual relationships with the ability to reproduce.

1 Consider that the client most likely will be able to have reflex penile erections.

After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide? 1 Lower extremities are paralyzed. 2 Upper extremities are paralyzed. 3 One side of the body is paralyzed. 4 Both lower and upper extremities are paralyzed

1 Lower extremities are paralyzed.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity? 1 Pushups to strengthen arm muscles 2 Leg lifts to prevent hip contractures 3 Balancing exercises to promote equilibrium 4 Quadriceps setting exercises to maintain muscle tone

1 Pushups to strengthen arm muscles

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. 1 Using Credé maneuver 2 Using an indwelling catheter 3 Using anticholinergic medications 4 Monitoring and restricting fluid intake to 800 mL daily 5 Monitoring for and reporting signs of urinary tract infection

1 Using Credé maneuver 5 Monitoring for and reporting signs of urinary tract infection

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse? 1 "You shouldn't give up hope." 2 "Being incapacitated is difficult for you." 3 "Would you like to speak to a religious advisor?" 4 "Have you talked to your family about your feelings?"

2 "Being incapacitated is difficult for you."

A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? 1 "I avoid use of a straw to drink liquids." 2 "I will take a hot bath to help relax my muscles." 3 "I plan to use an incontinence pad when I go out." 4 "I may be having a rough time now, but I hope tomorrow will be better."

2 "I will take a hot bath to help relax my muscles."

The family member of a client with newly diagnosed Guillain-Barre syndrome comes out to the nurse's station and informs the nurse that the client is having difficulty breathing. What is the first action the nurse should do? 1 Notify the healthcare provider. 2 Go with the family member to assess the client. 3 Send the nursing assistive personnel to take vital signs. 4 Assure the family member this is a normal response for this disease.

2 Go with the family member to assess the client.

During the neurologic assessment of a client with a tentative diagnosis of GuillainBarré syndrome, what does the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning

2 Increased muscular weakness

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television

2 Swimming

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? 1 "You may be able to lessen your feelings of guilt by seeking counseling." 2 "It would be helpful if you become involved in volunteer work at this time." 3 "I recognize it's hard to deal with this, but try to remember that this too shall pass." 4 "Joining a support group of people who are coping with this problem may be helpful."

4 "Joining a support group of people who are coping with this problem may be helpful."

An ambulatory client with relapsing-remitting multiple sclerosis is to receive everyother-day injections of interferon beta-1a. What adverse effects does the nurse explain may occur when taking this medication? Select all that apply. 1 Depression 2 Constipation 3 Flulike symptoms 4 Increased heart rate 5 Decreased perspiration

Correct 1 Depression Correct2 Constipation Correct3 Flulike symptoms Correct4 Increased heart rate

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Bladder dysfunction 5 Increased pulse pressure

Correct1 Bradycardia Correct2 Hypotension Correct4 Bladder dysfunction

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? 1 "You don't feel able to make a decision at this time?" 2 "Have you spoken to your fiancé about your feelings?" 3 "Your fiancé loves you and I'm sure still wants to marry you." 4 "These are your feelings now, but don't decide until you feel better and can cope.

1 "You don't feel able to make a decision at this time?"

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period? 1 Bladder control 2 Nutritional intake 3 Quadriceps setting 4 Use of aids for ambulation

1 Bladder control

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1 Arrangements will be made by the client and the client's family. 2 The plan is formulated and implemented early in the client's care. 3 The rehabilitation is minimal and short term, because the client will return to former activities. 4 Arrangements will be made for long-term care, because the client is no longer capable of selfcare.

2 The plan is formulated and implemented early in the client's care.

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation? 1 Place in a sitting position 2 Give nifedipine as prescribed 3 Examine for symptoms of pressure ulcers 4 Monitor blood pressure every 10 to 15 minutes

1 Place in a sitting position

The nurse is conducting a brief neurologic examination to test the level of consciousness in a client who sustained injuries in a bus accident. Which order should the nurse follow to assess the client's condition? 1. Asses if the client is alert. 2. Assess if the client is responsive to voice. 3. Assess if the client is responsive to pain. 4. Assess if the client is unresponsive. 5. Assess if the client has proper shape, size, equality, and reactivity in pupil

1. Asses if the client is alert. 2. Assess if the client is responsive to voice. 3. Assess if the client is responsive to pain. 4. Assess if the client is unresponsive. 5. Assess if the client has proper shape, size, equality, and reactivity in pupil **ALL ARE CORRECT

A client is admitted to the hospital with a diagnosis of acute Guillain-Barre syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange

4 Respiratory exchange

What nursing intervention is anticipated for a client with Guillain-Barré syndrome? 1 Providing a straw to stimulate the facial muscles 2 Maintaining ventilator settings to support respiration 3 Encouraging aerobic exercises to avoid muscle atrophy 4 Administering antibiotic medication to prevent pneumonia

2 Maintaining ventilator settings to support respiration

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 Headaches 2 Nystagmus 3 Skin infections 4 Scanning speech 5 Intention tremors

2 Nystagmus 4 Scanning speech 5 Intention tremors

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first? 1 Assess for the cause. 2 Place the client in sitting position. 3 Check the client for fecal impaction. 4 Give an alpha blocker prophylactically.

2 Place the client in sitting position.

The nurse is caring for a client with autonomic dysreflexia. What should be the nurse's immediate action to manage the client's condition? 1 Covering the client with blanket 2 Placing the client in a sitting position 3 Assessing the client's urinary retention 4 Administering alpha blockers to the client

2 Placing the client in a sitting position

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? 1 Take a hot bath. 2 Rest in an airconditioned room. 3 Increase the dose of muscle relaxants. 4 Avoid naps during the day.

2 Rest in an airconditioned room.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? 1 Encourage bed rest. 2 Space activities throughout the day. 3 Teach the limitations imposed by the disease. 4 Have one of the client's relatives stay at the bedside.

2 Space activities throughout the day.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment? 1 The injury results in loss of the reflex arc. 2 The injury is above the sixth thoracic vertebra. 3 There has been a partial transection of the cord. 4 There is a flaccid paralysis of the lower extremities.

2 The injury is above the sixth thoracic vertebra.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? 1 "Most individuals with your disease live a normal life span." 2 "Is your family here? I would like to explain your disease to all of you." 3 "The prognosis is variable; most individuals experience remissions and exacerbations." 4 "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

3 "The prognosis is variable; most individuals experience remissions and exacerbations."

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase? 1 Inhibiting urinary tract infections 2 Preventing contractures and atrophy 3 Avoiding flexion or hyperextension of the spine 4 Preparing the client for vocational rehabilitation

3 Avoiding flexion or hyperextension of the spine

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis? 1 Interleukin 2 2 Interleukin 11 3 Beta interferon 4 Alpha interferon

3 Beta interferon

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process? 1 Removing the cervical spine collar 2 Monitoring for autonomic dysreflexia 3 Implementing the logrolling technique 4 Administering the prescribed pain medication

3 Implementing the logrolling technique

The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following findings indicates to the nurse that the client is experiencing a complication of the labor process? 1 Increased pulse rate 2 Increased urine output 3 Increased blood pressure 4 Flaccidity in the lower extremities

3 Increased blood pressure

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? 1 Progressive deterioration until death 2 Deficiencies of essential neurotransmitters Correct 3 Increased risk for respiratory complications 4 Involuntary twitching of small muscle groups

3 Increased risk for respiratory complications

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action? 1 Begin teaching self-catheterization. 2 Develop a plan to ensure high fluid intake. 3 Palpate the suprapubic area of the abdomen. 4 Initiate a regimen to monitor urinary output.

3 Palpate the suprapubic area of the abdomen.

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client? 1 Performing vagal maneuver 2 Performing Valsalva maneuver 3 Performing jawthrust maneuver 4 Performing oculocephalic maneuver

3 Performing jawthrust maneuver

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee ground material and appears restless and apprehensive. What is the most important initial nursing action? 1 Change the client's diet to bland. 2 Obtain a stool specimen for occult blood. 3 Prepare for insertion of a nasogastric tube. 4 Monitor recent laboratory reports for hemoglobin levels.

3 Prepare for insertion of a nasogastric tube.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia? 1 Flaccid paralysis and numbness 2 Absence of sweating and pyrexia 3 Escalating tachycardia and shock 4 Paroxysmal hypertension and bradycardia

4 Paroxysmal hypertension and bradycardia

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary? 1 Reflexes have been lost. 2 There is partial transection of the cord. 3 There is damage above the sixth thoracic vertebra. 4 Flaccid paralysis of the lower extremities has occurred

3 There is damage above the sixth thoracic vertebra.

A nurse is caring for a client with a spinal cord injury. What is the specific reason fluid intake should be increased for this client? 1 To prevent dehydration 2 To maintain electrolyte balance 3 To prevent a urinary tract infection 4 To limit an increase in temperature

3 To prevent a urinary tract infection

The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client? 1 "The client will understand limitations." 2 "The client will consider lifestyle changes." 3 "The client will perform independent ambulation." 4 "The client will carry out personal hygiene activities."

4 "The client will carry out personal hygiene activities."

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse? 1 "Do you want me to get someone else to change you?" 2 You shouldn't be embarrassed; this is part of my job." 3 "I'll be back in a little while; why don't you rest until then?" 4 "While I'm bathing you I'll start teaching you about bowel training."

4 "While I'm bathing you I'll start teaching you about bowel training."

The respiratory status of a client with Guillain-Barre syndrome progressively deteriorates, and a tracheostomy is performed. Nasogastric tube feedings are prescribed. How should the nurse manage the tracheostomy cuff? 1 Deflate the cuff before starting each tube feeding 2 Inflate the cuff for one hour before and after each feeding 3 Deflate the cuff after the tube feeding has been completed 4 Inflate the cuff before the feeding and for 30 minutes after each feeding

4 Inflate the cuff before the feeding and for 30 minutes after each feeding

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? 1 Virusinduced iritis 2 Intracranial pressure 3 Closedangle glaucoma 4 Optic nerve inflammation

4 Optic nerve inflammation

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report? 1 The tremors increase when I fall asleep. 2 The tremors increase when I feel fatigued. 3 The tremors increase when I become nervous. 4 The tremors increase when I perform an activity.

4 The tremors increase when I perform an activity.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? 1 "That must have really shocked you. Tell me what the healthcare provider told you about it." 2 "You should see a psychiatrist who will help you cope with this overwhelming news." 3 "Don't worry; early treatment often alleviates symptoms of the disease." 4 "You should be glad that we caught it early so it can be cured."

1 "That must have really shocked you. Tell me what the healthcare provider told you about it."

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply. 1 Double vision 2 Resting tremors 3 Flaccid paralysis 4 Scanning speech 5 Mental retardation

1 Double vision 4 Scanning speech 5 Mental retardation

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 1 Dehydration 2 Skin breakdown 3 Electrolyte imbalances 4 Urinary tract infections

4 Urinary tract infections

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do? 1 Plan a schedule of specific times each day that will be set aside for playtime with the children. 2 While in remission, provide support to other people with multiple sclerosis who also have young children. 3 Develop a flexible schedule for completion of routine daily activities. 4 Meet with a self help group for people with the diagnosis of multiple sclerosis.

3 Develop a flexible schedule for completion of routine daily activities.

A nurse is caring for a client with the diagnosis of Guillain-Barre syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? 1 Auscultate for breath sounds. 2 Suction the client's oropharynx. 3 Administer and continue to monitor oxygen via nasal cannula. 4 Place the client in the orthopneic position.

2 Suction the client's oropharynx.

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? 1 Urinary frequency due to bladder spasticity 2 Urinary retention due to bladder atony 3 Pain due to urinary tract calculi 4 Urinary urgency due to urinary tract infections

2 Urinary retention due to bladder atony

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response? 1 Hemodynamic changes related to tilt table positioning 2 Deteriorating myelin sheath 3 Distended large intestine 4 Crushed spinal cord

3 Distended large intestine

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply. 1 Spasticity 2 Incontinence 3 Flaccid paralysis 4 Respiratory failure 5 Lack of reflexes below the injury

3 Flaccid paralysis 5 Lack of reflexes below the injury Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected