Nursing 2 - Ch 64 Management of Patients w Neurologic Infections, Autoimmune Disorders, and Neuropathies

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?" Explanation: An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis - The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis.

The rehabilitation nurse is caring for a 25-year-old client who suffered extensive injuries in a motorcycle accident. During each interaction with the client, what action should the nurse perform most frequently?

Evaluate the client's positioning. During each client contact, the nurse evaluates the client's position and assists the client to achieve and maintain proper positioning and alignment.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

Multiple scheloris

Loss of proprioception

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it. The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

alternatively patch an eye q2 hrs ARR

Neurologic deficit

central and peripheral nervous systems with decreased, impaired, or absent functioning

Guillain-Barre syndrome

inflammation of the myelin sheath of peripheral nerves, characterized by rapidly worsening muscle weakness that may lead to temporary paralysis uneven, labored respirations

reflex (neurogenic) incontinence

is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void

functional incontinence

occurs in patients with intact urinary physiology but who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves.

A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

opposition

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

overmedication

urge incontinence

refers to the involuntary elimination of urine associated with a strong perceived need to void

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate?

"Keep your fluid intake to fewer than 2 liters per day." To promote bowel elimination, the nurse should suggest a daily fluid intake of 2 to 3 liters per day unless contraindicated and encourage the patient to respond to the urge to defecate. Increasing the intake of fruits and vegetables and encouraging an increase in physical activity are appropriate to stimulate peristalsis.

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)

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 intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium. Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time?

After breakfast

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre. med surge p. 2103

stress incontinence

occurs when perineal muscles weaken. Urine subsequently leaks when the intra-abdominal pressure increases, such as with sneezing or coughing.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.

Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.

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)

A frontal lobe brain abscess produces which manifestation?

seizures