Chapter 37: Caring for Clients With Central and Peripheral Nervous System Disorders

The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply

-Elevated systolic blood pressure -Wide pulse pressure

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

. Urinary tract infection

The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?

An absence seizure

An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?

Brain tumor

The nursing instructor gives students an assignment of making a plan of care for a client with Huntington disease. What would be important for the students to include in the teaching portion of the care plan?

How to facilitate tasks such as using both hands to hold a drinking glass

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Lactated Ringer's

The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client? ?

Maintaining a safe environment

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?

muscle spasms

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?

Turn client to side-lying position

A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply

-"In the early stages, people with the disease can participate in most physical activities." -"The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements." -"Disease-modifying medications for Huntington disease can decrease immune cells and infection protection."

The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply

-Cloudy cerebral spinal fluid -Purpura of hands and feet

A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply.

-Medication regimen -Appointments for chemotherapy or radiotherapy -Adverse effects of chemotherapy or radiation and techniques for managing them -Nutritional support

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?

Administer medications at exact intervals ordered.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is most important for the nurse to do with this client?

Explaining hospice care and services

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation occurs through the foramen magnum.

The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?

Increased intracranial pressure

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

A client the nurse is caring for experiences a seizure. What would be a priority nursing action?

Protect the client from injury.

The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event?

Seizure was 1 minute in duration including tonic-clonic activity

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 is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?

Use ophthalmic lubricant and protect the eye.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which assessment finding by the nurse would be most significant in the diagnosis of this client?

Vector bites

The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?

"My children are at greater risk to develop this disease."

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?

Damage to the nerves that facilitate vision and hearing