Brunner-Suddarth Med-Surg 13th Ed. Ch. 69

A 43-year-old female literature teacher with a neurologic deficit is feeling frustrated because since her stroke, she can no longer pronounce words without great difficulty. Which of the following is the client struggling with?

Dysarthria

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)

The nurse is preparing the patient for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which of the following is the priority nursing action?

Ensure atropine is readily available.

A 67-year-old firefighter now has a neurological defect and has been informed that he will be transferred to a nursing home because his son is unable to care for him at home. While receiving a bed bath, the patient 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.

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?"

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

"I was brushing my teeth."

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

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

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary."

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

At what rate (in drops per minute) should a nurse start an I.V. infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number ONLY.

45

Which of the following statements best defines a neurologic deficit?

A deficit of the central and peripheral nervous systems with decreased, impaired, or absent functioning

The nurse is volunteering for a Red Cross blood drive and is taking the history of potential donors. Which volunteer would the nurse know will not be allowed to donate blood?

A donor who was in college in England for 1 year

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?

Antibodies are removed from the plasma.

Which of the following nursing interventions is appropriate for a patient with double vision in the right eye due to MS?

Apply an eye patch to the right eye.

Which drug should be available to counteract the effect of Tensilon?

Atropine

The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing?

Brain abscess

Which of the following is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased ICP

Which of the following is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.

Decreased glucose Increased protein Increased white blood cells

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

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

Herpes simplex virus (HSV)

A 68-year-old retired salesman was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how the client reported a severe headache and then was unable to talk or move his right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would you expect basic rehabilitation to begin?

Immediately

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

The diagnosis of multiple sclerosis is based upon which of the following tests?

MRI

The diagnosis of multiple sclerosis is based on which of the following tests?

Magnetic resonance imaging (MRI)

An 89-year-old retired government clerk is being admitted to your rehabilitation hospital as a result of the tetraplegia caused by stroke. Her condition is stable, and after admission, she will begin physical and psychological therapy. An important part of your nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?

Maintain sufficient integument capillary pressure

The primary North American vector transmitting arthropod-borne virus encephalitis is which of the following?

Mosquito

Which of the following is the primary vector of arthropod-borne virus encephalitis in North America?

Mosquitoes

Which of the following is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

Multiple sclerosis

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

Multiple sclerosis

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

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment?

Neurovascular system

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

Overmedication

Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?

Polymerase chain reaction (PCR)

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?

Positive Kernig's sign

Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible?

Prevent complications, which may interfere with recovering function.

Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)?

Providing supportive care

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

Reduced muscle spasticity

A patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). To ensure early intervention, the nurse monitors laboratory values and urine output for which of the following adverse reactions?

Renal

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

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.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

The primary North American vector transmitting arthropod-borne virus encephalitis is the

mosquito

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.

A discharge nurse in a rehabilitation facility is coordinating the discharge of a 47-year-old man who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?

Spouse

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.

An 86-year-old retired banker is 10 years status post-CVA and has been a resident for 7 years in the long-term care facility where you practice nursing. Twice a week, the client attends group counseling and physical therapy sessions even though he has contractures and hasn't walked since his original stroke. Why does he receive physical and psychological therapy?

To prevent complications

Which of the following is the priority nursing intervention for a patient in myasthenic crisis?

Assessing respiratory effort

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