PrepU chapter 64

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

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

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus (HSV)

A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. The nurse planning the client's care. Who will the client's condition affect?

Him and his entire family

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement?

Holds onto the furniture when walking in the house

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?

Include client in planning of care and setting of goals.

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

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which nutritional deficiency may delay wound healing?

Lack of vitamin C

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging

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

"Avoid hot baths and showers."

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?"

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?

"I need to allow my arms and hands to support my body weight."

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

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."

A nurse is describing the concept of rehabilitation to a group of families who have members in need of these services. Which statement would the nurse include in the description?

"Rehabilitation focuses on the person's abilities."

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?

"The client may be experiencing a change in affect due to the brain injury."

A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching?

"This disease doesn't cause sensory impairment."

A client admitted with meningitis is to receive Vancocin (vancomycin) 250 mg in 100 mL intravenously over 60 minutes twice a day. The IV tubing set is calibrated at 15 drops per/mL. At how many drops per minute will the nurse run this solution? Enter the correct number ONLY.

25

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

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

Alternatively patch one eye every 2 hours.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.

Bathing Toileting Eating

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Cerebellar abscess

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

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours.

An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?

Isometric

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of knees and hips

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

Overmedication

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

Positive Brudzinski sign

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures.

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?

Priority setting is helpful in dealing with the impact of the disability.

A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?

Prone

Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?

Providing palliative care

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?

Providing supportive care

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

Stress incontinence

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 patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?

The client will experience grief in an individualized manner.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

The patient

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

An adult client's current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a client who has self-care deficits in ADLs?

To provide an optimal learning environment with minimal distractions

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

Trigeminal neuralgia

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing?

Vitamin C

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?

With initial patient contact

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

advance both crutches.

The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's:

range of motion.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.