ch 69 Neurologic Infections, Autoimmune Disorders, and Neuropathies prepU
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
Multiple sclerosis
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.
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
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine
A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:
Acute attacks with full recovery or residual deficit upon recovery.
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 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."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether 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."
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?
Approximately 60% to 75% of clients recover completely.
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
Avoid hot temperatures. Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue
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
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus (HSV)
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
Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?
Providing supportive care vCJD is a progressive fatal disease, and no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative.
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
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?
Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of MS.
A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?
Within 24 hours after exposure
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at
controlling seizures and increased intracranial pressure.
A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?
initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions.
The primary arthropod vector in North America that transmits encephalitis is the
mosquito.
The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include
sensory disturbance, limb pain, and behavioral changes.
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?
Renal
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
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
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."
At what rate (in drops per minute) should a nurse start an IV 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
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 nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?
Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced.
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 performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily?
Respiratory Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency.
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.
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 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 nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?
Bacteria