Med/Surg 2: Exam 2

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. 1. Double vision 2. Problems with cognition 3.Difficulty swallowing saliva 4. Intention tremors of the hands 5. Drooping of the upper eyelids 6. Nonintention tremors of the extremities

1. Double vision 3. Difficulty swallowing saliva 5. Drooping of the upper eyelids Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

The nurse is caring for a client who underwent surgery for a brain tumor. On assessment, the nurse suspects meningitis in the client. Which finding would help confirm the nurse's suspicion? 1. Positive Kernig's sign 2. Glasgow coma scale: 10 3. Absence of nuchal rigidity 4. Negative Brudzinski sign

1. Positive Kernig's sign Meningitis may occur secondary to surgical procedures on the brain. It is highly probable when Kernig sign is positive. The Glasgow coma scale is used as a reliable way of recording the conscious state of the client, but it is not used to diagnose meningitis. A meningitis diagnosis is highly probable with a positive Brudzinski sign and the presence of nuchal rigidity (e.g., stiff neck).

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? 1. Problems with cognition 2. Difficult swallowing saliva 3. Intention tremors of the hands 4. Nonintention tremors of the extremities

2. Difficulty swallowing saliva Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength? 1. Partial improvement of muscle strength with mild exercise 2. Fluctuating weakness of muscles innervated by the cranial nerves 3.Little change regardless of the therapy initiated 4. Dramatic worsening with anticholinesterase drugs

2. Fluctuating weakness of muscles innervated by the cranial nerves Use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected, and therefore muscle weakness will fluctuate in relation to activity and rest. Muscle strength decreases, not increases, with activity. Anticholinesterase drugs improve muscle strength.

The nurse is conducting a neurologic assessment on a client brought to the emergency room after a motor vehicle accident. While assessing the client's response to pain, the client pulls his arms upward and inward. The nurse recognizes that this response represents an injury to what part of the brain? 1. Frontal lobe 2. Midbrain 3. Pons 4. Brainstem

2. Midbrain Decorticate posturing [1] [2] [3] is a sign of significant deterioration in a client's neurologic status and is manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses in the above listed areas.

A client comes into the emergency room (ER) after hitting his head while playing basketball. He is alert and oriented. Which is a priority nursing intervention? 1. Assess full range of motion (ROM) to determine extent of injuries. 2. Call for an immediate head computed tomography (CT). 3. Immobilize the client's head and neck. 4. Open the airway with the head-tilt chin-lift maneuver.

3. Immobilize the client's head and neck. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. The head CT would be prescribed next. The airway does not need to be opened because the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver would not be used until the cervical spine injury is ruled out.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, what specific range-of-motion exercise should the nurse teach the client? 1. Eversion 2. Supination 3. Opposition 4. Circumduction

3. Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

A client reports buzzing in the ear for the past 5 days and a decreased ability to hear sounds. After interacting with the client, the nurse finds that the client is receiving long-term aminoglycoside therapy. Which cranial nerve should the nurse suspect to be affected? 1. CN III 2. CN V 3. CN VII 4. CN VIII

4. CN VIII CN VIII is the vestibulocochlear nerve, a part of central auditory system. Medications such as aminoglycosides are ototoxic and can damage CN VIII and cause hearing loss, tinnitus (buzzing in ears), and vertigo. CN III is the oculomotor nerve that innervates the iris sphincter muscle. This muscle helps in pupil constriction. CN V is the trigeminal nerve that innervates the iris dilator muscle involved in the dilation of the pupil. CN VII is the facial nerve, which innervates the muscles that help open and close the eyelids.

A client who sustained a closed head injury is being monitored for increased intracranial pressure. Arterial blood gases are obtained, and the results include a PCO2 of 33 mm Hg. What action is most important for the nurse to take? 1. Encourage the client to slow the breathing rate. 2. Auscultate the client's lungs and suction if indicated. 3. Advise the healthcare provider that the client needs supplemental oxygen. 4. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure

4. Inform the healthcare provider of the results and continue to monitor for signs of increasing intracranial pressure A lower than expected PCO2 actually will benefit the client because it reduces intracranial pressure by preventing cerebral vasodilation; the results should be reported, and monitoring for signs and symptoms of increased intracranial pressure [1] [2] should continue (restlessness, confusion and lethargy, pupillary and oculomotor dysfunction, hemiparesis or hemiplegia of the contralateral side, projectile vomiting without nausea, increased systolic pressure, widening pulse pressure and bradycardia, and altered breathing pattern). Instructing the client to slow the breathing rate is inappropriate because it will elevate the PCO2, which will increase intracranial pressure. There is no evidence that suctioning is indicated; suctioning increases intracranial pressure and therefore should be avoided unless absolutely necessary to maintain a patent airway. There is no evidence that supplemental oxygen is needed; an abnormal PCO2 does not indicate the need for supplemental oxygen.

A client has a history of diabetes mellitus. After assessing the client, the primary healthcare provider confirms damage to the sensory limb of the bladder spinal reflex arc. Which clinical manifestations could confirm this condition? 1. Incomplete voiding 2. Overdistention of bladder 3. Lack of control on micturition 4. Infrequent voiding of large residual volumes

4. Infrequent voiding of large residual volumes Damage to the sensory limb of the bladder spinal reflex arc is a type of sensory neurogenic bladder where the client lacks the sensation of needing to urinate. This is usually seen in clients with multiple sclerosis and diabetes mellitus. Its clinical manifestation is infrequent voiding of large residual volumes. Incomplete voiding is a symptom of reflexic neurogenic bladder. Overdistention of the bladder and lack of control on micturition are the symptoms of areflexic neurogenic bladder.

What are the reasons for performing a lumbar puncture on a client? Select all that apply. 1.Confirming spinal cord injuries 2. Assessing sensory nerve problems 3. Measuring blood flow in many areas 4. Reading cerebrospinal fluid pressure 5. Injecting contrast medium for diagnostic study

4. Reading cerebrospinal fluid pressure 5. Injecting contrast medium for diagnostic study A lumbar puncture is the insertion of a spinal needle into the subarachnoid space between the third and fourth lumbar vertebrae; it can be used to obtain cerebrospinal fluid readings with a manometer. Using a lumbar puncture, contrast medium or air is injected for diagnostic study. Evoked potentials measure the electrical signals to the brain generated by sound, light, or touch, and are used to confirm neurologic conditions like spinal cord injuries and multiple sclerosis. Evoked potentials are also used to assess sensory nerve problems. Cerebral blood flow evaluation is used to measure blood flow in many areas using radioactive substances.