NCLEX Musculoskeletal & Neurological disorders

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?

"I take the medication at bedtime."

Continuous Passive Motion (CPM)

-Continuously flexes and extends the knee to prevent scar tissue from forming and increasing gradually

Treatment of compartment syndrome

-Elevate extremity (get fluid away) -soft cast then rigid cast -Loosen the cast to restore circulation -Be careful in picking the answer to "remove the cast" -fasciotomy -cast cutters to remove the case (instruct them the cast saw does not touch the skin, but it does vibrate)

Immediate Post Op care for amputations

-Keep a tournaquette at the bedside -Extension to prevent hip/knee contractions -Inspect the residual limb daily to be sure that it lies completely flat on the bed

Post-Op care for the hip replacement patient

-Neurovascular checks -Monitor drains (don't want fluid to accumulate in tissue) -Firm mattress (joints need support) -Over-bed trapeze to build upper body strength -isometric exercises while in bed -no weight bearing until ordered -hydrate! -stresses to the new hip joint should be minimal in the first 3-6 months -no sleeping on the operative side -do not give pain meds in the operative hip

Should you relieve traction?

-Never relieve traction unless you've got a physician's order

Infection (after hip surgery)

-Prophylactic antibiotics -remove foley and drains as soon as possible

Phantom Pain

-Seen more with AKA (above knee) -Diversional activity is the first thing to do -Usually subsides in 3 months

Complications with Fractures include:

-Shock (hypovolemic) -Fat embolism -compartment syndrome

More cast care points after the cast is dry

-Watch for breakthrough bleeding (mark the area, circle it, date, and sign site, notice if it is bigger) -cover cast close to groin with plastic once it is dry -neuro-vascular checks with the 5 P's

What do you do if your client complains of pain after the cast is dry?

-assess neurovascular -Most pain is relieved by elevation, cold packs, and analgesics (if these things do not relieve pain, think complication)

Amputations (where are they performed?)

-at the most distal point that will heal -Doc tries to preserve the elbows and knees

What is the purpose of traction?

-decrease muscle spasms -reduces (realigns) -Immobilizes

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

A client in a nursing home is diagnosed with Alzheimer's disease. He exhibits the following symptoms: difficulty with recent and remote memory, irritability, depression, restlessness, difficulty swallowing, and occasional incontinence. This client is in what stage of Alzheimer's disease?

II

Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

In 10 to 15 minutes

In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation?

Increased restlessness

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?

Powerlessness

A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The spouse tells the nurse of feeling guilty for letting the accident happen and reports not sleeping well because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse?

Risk for caregiver role strain related to increased client care needs

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?

Schedule the medication before meals.

A 78-year-old Alzheimer's client is being treated for malnutrition and dehydration. The nurse decides to place him closer to the nurses' station because of his tendency to:

wander.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers."

When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?

"Be aware that your urine may appear darker than usual."

The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?

"Are you allergic to seafood or iodine?"

What assessment is most important with fractures?

neuro-vascular checks -Pulse, Color, Movement, Sensation, Cap refill, and temp

What is the sign of mal-union?

persistent discomfort with moving (broken bones should not be moving under the cast)

What to do with open fractures

sterile-dressing covering

Client Education for Rehab after hip surgery

-best exercising is walking -Avoid flexion (low chairs, traveling long distances, sitting more than 30 minutes, lifting heavy objects, excessive bending or twisting, stair climbing)

Avascular Necrosis (after hip surgery)

-death of tissue due to poor circulation

S/S of fat emboli

-depends on where emboli goes petechia or rash over chest conjunctival hemorrhages snow storm on CXR young males first 36 hours of the fracture (after that it is the DVT)

Compartment Syndrome

Increased pressure within a limited space

Cast Care in first 24 hours after molding

-ice packs on the side for the first 24 hours because the cast is still wet -no indentations -use palms of hands for the first 24 hours when cast is still wet -Keep uncovered and allow for air dry -Do not rest cast on hard surface or sharp edge (use soft pillow, no plastic)

Elevation post amputation

-it is controversial, because of hip contractures -Only elevate for a short time to reduce swelling -Do not elevate on a pillow, elevate the foot of the bed

Positioning for post-op hip replacement

-neutral rotation-toes to the ceiling -limit flexion; want extension of the hip -Abduction -trochanter roll to promote external rotation -Avoid crossing legs and bending over

Things to remember post knee surgery

-never hyper extend or hyperflex the knee -neurovascular checks -pain relief

S/S of fractures

-pain and tenderness -unnatural movement -deformity (possible) -shortening of the extremity (caused by muscle spasm) -crepitus (bones grating together) -swelling -discoloration -worry about compartment syndrome

Is it ok to massage the stump?

-promotes circulation and decreases tenderness

Common areas for compartment syndrome

-quads -forearms

What is skin traction?

-used short term to relieve muscle spasms and immobilize until surgery -This is when tape or some type of material is stuck to the skin and the weights pull against it. The skin is NOT penetrated

Other Notes to remember about traction

-weights should hang freely -keep patient pulled up in bed and centered with a good alignment -exercise non-immobilized joints -ropes should move freely and knots should be secure/tight -special air filled or foam mattress

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move him to a flat surface and turn him on his side.

Dislocation (after hip surgery)

circulatory/nerve damage S/S: shortening of leg, abnormal rotation, can't move extremity, PAIN

The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it:

constricts cerebral blood vessels.

Should contraction be intermittent or continuous?

continuous! Never relieve traction without a doc's order

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

destruction of acetylcholine receptors.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG).

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

The nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

What is worn under the prosthesis?

limb sock

Types of Skeletal traction

Steinman pins Crutchfield Gardner-Wells tongs Halo vest

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?

Succinylcholine (Anectine)

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters

A client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?

Urine retention or incontinence

The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

Vision changes

The nurse is planning care for a client with multiple sclerosis. Which three problems should the nurse expect the client to experience?

Visual disturbances Balance problems Mood disorders

A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant?

Even, unlabored respirations

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

Ineffective airway clearance

What occurs in the post-ictal period?

Patient sleeps for several hours after seizure. Do not call physician because this is expected.

Treatment of Fractures

-Immobilize the bone ends plus the adjacent joints -support fracture above and below the site -move extremity as little as possible -splints help prevent fat emboli and muscle spasm

Fracture Healing Concerns

-delayed union (healing does not occur at a normal rate) -Non-union (failure of bone ends to unite; may require bone grafting) -Mal-union: deformity at the fraction site

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

Why is limb shaping important post amputation?

prosthesis -you want the end to be shaped like a cone (smaller and rounded at the bottom)

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?

"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain.", "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?

"I'm sorry you haven't been bathed. I'm available to bathe you now."

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?

"It's important for us to have this information. You should review the document with your physician at every admission."

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?

"The paralysis caused by this disease is temporary."

Skeletal Traction

-Applied directly to the bone with pins and wires -Used with prolonged traction is needed

Patho of Compartment Syndrome

-fluid accumulates in the tissue and impairs tissue perfusion -The muscle becomes swollen and hard and the client complains of severe pain that is not relieved with pain meds -Pain is unpredictable -Pain is disproportionate to the injury, if undetected, it may result in nerve damage and possible amputation

What type of fractures do you see with fat embolisms?

-pelvic, long bones, crushing injuries

How do you toughen the stump?

-press into a soft pillow -then a firm pillow -then on the bed -then on a chair or wall

A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity?

1 to 2 weeks

Complications post-op from hip replacement (4)

1. Dislocation 2. Infection 3. Avascular necrosis 4. Immobility problems

A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

10 to 20 mcg/ml

For a client with a head injury whose neck has been stabilized, the preferred bed position is:

30-degree head elevation.

The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:

Alzheimer's disease.

A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?

Assist the client to a side-lying position on the floor, and protect her with linens.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?

Assist the client to the floor. Turn the client to his side. Place a pillow under the client's head.

What is the most famous type of skin traction?

Buck's (used most often with hip and femoral fractures) Must do a good skin assessment with these

Pre-op notes about Total Hip Replacement: what type of traction is used?

Buck's is frequently used

A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

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 undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?

Excessive gum tissue growth

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan?

Furnish the client's environment with familiar possessions., Assist the client with activities of daily living (ADLs) as necessary., Assign tasks in simple steps.

A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?

Intestinal obstruction

What is an aura?

It is a foreknowledge that a seizure is going to occur

A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?

Monitor for skin rash. Perform good oral hygiene, including daily brushing and flossing., Periodic follow-up blood work is necessary. Report to the physician problems with walking and coordination, slurred speech, or nausea.

Pin care

Monitor the site sterile technique remove crusts serous drainage is ok

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in a room set at a comfortable temperature.

To encourage adequate nutritional intake for a client with Alzheimer's disease, the nurse should:

stay with the client and encourage him to eat.

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:

thymus gland hyperplasia.

A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:

treatment of spasticity associated with spinal cord lesions.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.