Parkinson's/MS
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? A. At bedtime B. All at one time C. Two hours before mealtime D. At the time scheduled
RATIONALE: While the client is hospitalized for adjustment of medication, it is essential that the medications be administered exactly at the scheduled time, for accurate evaluation of effectiveness. For example, levodopa-carbidopa (Sinemet) is taken in divided doses over the day, not all at one time, for optimum effectiveness. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Apply CORRECT ANSWER: D
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? A. Double vision B. Sudden bursts of energy C. Weakness in the extremities D. Muscle tremors
RATIONALE: With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. Select All That Apply A. Carefully test the temperature of bath water B. Avoid kitchen activities because of the risk of injury C. Avoid hot water bottles and heating pads D. Inspect the skin daily for injury or pressure points E. Wear warm clothing when outside in cold temperatures
RATIONALE: A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Create CORRECT ANSWER: A,C,D,E
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? A. Psychotherapy B. Regular exercise C. Day care for the granddaughter D. Weekly visits by another person with MS
RATIONALE: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? A. Encouraging the client to speak slowly B. Encouraging the client to speak distinctly C. Asking the client to repeat indistinguishable words D. Asking the client to speak louder when tired
RATIONALE: Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-tounderstand words helps the client to communicate effectively. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? A. Induces sleep B. Stimulates the client's appetite C. Relieves muscular spasticity D. Reduces the urine bacterial count
RATIONALE: Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms common in MS. Drowsiness is an adverse effect, and driving should be avoided if the medication produces a sedative effect. Baclofen does not stimulate the appetite or reduce bacteria in the urine. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: C
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? A. Early in the morning, when the client's energy level is high B. To coincide with the peak action of drug therapy C. Immediately after a rest period D. When family members will be available
RATIONALE: Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are managed with drug therapy. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? A. The client exhibits intolerance to many drugs B. The client experiences spontaneous remissions from time to time C. The client requires multiple drugs simultaneously D. The client endures long periods of exacerbation before the illness responds to a particular drug
RATIONALE: Evaluating drug effectiveness is difficult because a high percentage of clients with MS exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is not what makes evaluation of drug effectiveness difficult. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B
Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease? A. To cure the disease B. To stop progression of the disease C. To begin preparations for terminal care D. To maintain optimal body function
RATIONALE: Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. Many clients live for years with the disease, however, and it would not be appropriate to start planning terminal care at this time. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D
A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy? A. Mood B. Muscle rigidity C. Appetite D. Alertness
RATIONALE: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Evalulate CORRECT ANSWER: B
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate? A. Eating a diet high in fiber B. Setting a regular time for elimination C. Using an elevated toilet seat D. Limiting fluid intake to 1,000 mL/day
RATIONALE: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: D Continue
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: A. Develop joint mobility B. Develop muscle strength C. Develop cognition D. Develop mood elevation
RATIONALE: MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. MS affects speech, coordination, and vision, but not cognition. Care for the client with MS is directed toward maintaining joint mobility, preventing deformities, maintaining muscle strength, rehabilitation, preventing and treating depression, and providing client motivation. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? A. Limit fluid intake to 1,000 mL/day B. Insert an indwelling urinary catheter C. Establish a regular voiding schedule D. Administer prophylactic antibiotics, as ordered
RATIONALE: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. Select All That Apply A. Restrict fluids to 1,000 mL/24 hours B. Drink 400 to 500 mL with each meal C. Drink fluids midmorning, midafternoon, and late afternoon D. Attempt to void at least every 2 hours E. Use intermittent catheterization as needed
RATIONALE: Maintaining urinary function in a client with neurogenic bladder dysfunction from MS is an important goal. The client should ideally drink 400 to 500 mL with each meal; 200 mL midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent infection and stone formation. The client may need to catheterize herself to drain residual urine in the bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder training for nighttime continence, the client may restrict fluids for 1 to 2 hours before going to bed. The client should drink at least 2,000 mL every 24 hours. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Create CORRECT ANSWER: B,C,D,E
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? A. Tell the client firmly that she needs assistance and help her with her care B. Praise the client for her desire to be independent and give her extra time and encouragement C. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help D. Suggest to the client that if she insists on selfcare, she should at least modify her routine
RATIONALE: Ongoing self-care is a major focus for clients with Parkinson's disease. The client should be given additional time as needed and praised for her efforts to remain independent. Firmly telling the client that she needs assistance will undermine her self-esteem and defeat her efforts to be independent. Telling the client that her perception is unrealistic does not foster hope in her ability to care for herself. Suggesting that the client modify her routine seems to put the hospital or the nurse's time schedule before the client's needs. This will only decrease the client's self-esteem and her desire to try to continue self-care, which is obviously important to her. CLIENT NEED: Psychosocial adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B
The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? A. Impaired mobility related to spasticity and fatigue B. Risk for falls related to muscle weakness and sensory loss C. Risk for seizures related to muscle tremors and loss of myelin D. Impaired skin integrity related bowel and bladder incontinence
RATIONALE: Symptoms that can occur with multiple sclerosis are muscle spasticity and weakness, fatigue, visual disturbances, hearing loss, and bowel and bladder incontinence. Seizures are not associated with myelin destruction. CLIENT NEED: Management of care; COGNITIVE LEVEL: Evaluate CORRECT ANSWER: C
Which of the following is an initial sign of Parkinson's disease? A. Rigidity B. Tremor C. Bradykinesia D. Akinesia
RATIONALE: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B
A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved: A. Functional ability B. Emotional stress C. Alertness D. Appetite
RATIONALE: The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite. CLIENT NEED: Basic care and comfort; COGNITIVE LEVEL: Apply CORRECT ANSWER: A
A health care provider has ordered carbidopa- levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. Select All That Apply A. Explain that the new prescription for Sinemet will treat his depression B. Encourage the client to discuss his feelings as the Sinemet is being administered C. Contact the health care provider before administering the Sinemet D. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors E. Determine if the client is at risk for suicide
RATIONALE: The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss his feelings is appropriate when the prescription is finalized. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C,D,E
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: A. "You will need to accept the necessity for a quiet and inactive lifestyle." B. "Keep active, use stress reduction strategies, and avoid fatigue." C. "Follow good health habits to change the course of the disease." D. "Practice using the mechanical aids that you will need when future disabilities arise."
RATIONALE: The nurse's most positive approach is to encourage a client with MS to keep active, use stress reduction strategies, and avoid fatigue because it is important to support the immune system while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help minimize complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: B
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? A. "Has an intention tremor of the right hand." B. "Right-hand tremor worsens with purposeful acts." C. "Needs assistance with dressing and eating due to severe trembling and clumsiness." D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
RATIONALE: The nurses' notes should be concise, objective, clearly stated, and relevant. This client trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This activity should be described exactly as it occurs so that others reading the note will have no doubt about the nurse's observation of the client's behavior. Identifying the "intentional" activity of daily living will help the interdisciplinary team individualize the client's plan of care. Clarifying what is meant by "worsening" with a purposeful act will facilitate the inter-rater reliability of the team. It is better to state what the client did than to give vague nursing orders in the nurses' notes. CLIENT NEED: Management of care; COGNITIVE LEVEL: Apply CORRECT ANSWER: D
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? A. Maintaining a balanced nutritional diet B. Enhancing the immune system C. Maintaining a safe environment D.Engaging in diversional activity
RATIONALE: The primary focus is on maintaining a safe environment because the client with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern. CLIENT NEED: Reduction of risk potential; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: C
What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? A. To maintain joint flexibility B. To build muscle strength C. To improve muscle endurance D. To reduce ataxia
RATIONALE: The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Synthesize CORRECT ANSWER: A
A client is being switched from levodopa (L-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? A. Euphoria B. Jaundice C. Vital sign fluctuation D. Signs and symptoms of diabetes
RATIONALE: Vital signs should be monitored, especially during periods of adjustment. Changes, such as orthostatic hypotension, cardiac irregularities, palpitations, and light-headedness, should be reported immediately. The client may actually experience suicidal or paranoid ideation instead of euphoria. The nurse should monitor the client for elevated liver enzyme levels, such as lactate dehydrogenase, aspartate amino- transferase, alanine aminotransferase, blood urea nitrogen, and alkaline phosphatase, but the client should not be jaundiced. The client should not experience signs and symptoms of diabetes or a low serum glucose level, but the nurse should check the hemoglobin and hematocrit levels. CLIENT NEED: Pharmacological and parenteral therapies; COGNITIVE LEVEL: Analyze CORRECT ANSWER: C
The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors? A. The tremors are probably psychological and can be controlled at will B. The tremors sometimes disappear with purposeful and voluntary movements C. The tremors disappear when the client's attention is diverted by some activity D. There is no explanation for the observation; it is probably a chance occurrence
RATIONALE: Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client. CLIENT NEED: Physiological adaptation; COGNITIVE LEVEL: Analyze CORRECT ANSWER: B