Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI) Explanation: The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed on MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?

Headache and nuchal rigidity Explanation: Headache and fever are the initial symptoms of meningitis. Nuchal rigidity can be an early sign. Photophobia is also a well-recognized sign in meningitis. Ptosis and diplopia are usually seen with myasthenia gravis. Hyporeflexia in the legs is seen with Guillain-Barre syndrome.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it. Explanation: The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

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." Explanation: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision Explanation: Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine Explanation: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.

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

Antibodies are removed from the plasma. Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye. Explanation: An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the client. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a client with double vision. Needed items should be placed on the unaffected (left) side.

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 Explanation: Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.

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

Controlling seizures and increased intracranial pressure Explanation: There is no specific medication for arboviral encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.

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 Explanation: The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

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) Explanation: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma.

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

Ensure atropine is readily available. Explanation: Atropine should be ready before administration of edrophonium chloride so it is available if needed to control the side effects of the medication. Assessing facial weakness and documenting the results occur after the administration of edrophonium chloride; therefore, they are not the priority interventions.

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

Facial Explanation: Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve. Trigeminal neuralgia is a paralysis of the trigeminal nerve (cranial nerve V). The optic nerve (cranial nerve II) functions in vision. The vestibulocochlear nerve (cranial nerve VIII) functions in hearing.

Bell palsy is a disorder of which cranial nerve?

Facial (VII) Explanation: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

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. Explanation: Helping the client perform ROM exercises every 8 hours helps in promoting joint flexibility and muscle tone in a client with muscle weakness. Measures such as using pressure-relieving devices or changing the body positions every 2 hours prevents skin breakdown. The nurse should use a footboard and trochanter rolls to promote a neutral body position that will keep the body in good alignment.

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. Explanation: The client in a rehabilitation setting has moved to the recovery phase. The highest priority is to include the client in the rehabilitation plan. Tailoring the rehabilitation plan to meet the needs of the client can promote optimal participation by the client in the rehabilitative process. The other options are appropriate in certain situations but not the highest priority

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 Explanation: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside?

Intubation tray and suction apparatus Explanation: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.

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

Multiple sclerosis Explanation: Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.

Nuchal rigidity Positive Kernig's sign Positive Brudzinski's sign Photophobia Explanation: Signs of meningeal irritation include nuchal rigidity (neck stiffness), a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Patients may have a fever.

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 Explanation: A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.

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 Explanation: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

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. Explanation: After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.

During the recovery phase of a neurologic deficit, assessment tools may be used to help identify a client's level of functioning. Which tool is used to measure performance in activities of daily living (ADL)?

The Barthel Index Explanation: On The Barthel Index, each performance ADL item is rated with a given number of points assigned to each level or ranking. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Uneven, labored respirations Explanation: A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness, evidenced by uneven, labored respirations, is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although warm, dry skin; urine output of 40 ml/hour; and a soft, nondistended abdomen are pertinent assessment data, those related to respiratory function and status are most significant.

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning. Explanation: A client with a neurologic deficit may have decreased, impaired, or absent functioning of the central and peripheral systems.

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications. Explanation: Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.

The primary arthropod vector in North America that transmits encephalitis is the

mosquito. Explanation: Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy. Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.

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." Explanation: Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

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." Explanation: A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.

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 Explanation: The nurse should administer 45 drops/minute. The formula is to divide 180 ml by 60 minutes, which yields 3 ml/minute; 3 ml/minute × 15 drops = 45 drops/minute.

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 Explanation: The prion exists in lymphoid tissue and blood in both Variant Creutzfeldt-Jakob Disease (vCJD) and Creutzfeldt-Jakob Disease (CJD). Both prion diseases are believed to be bloodborne. No method is available to screen blood for infectivity. For this reason, the American Red Cross will not accept blood donation from anyone who has traveled to the United Kingdom or Europe for more than 3 to 6 months (Benjamin, 2010).

A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario?

Copaxone Explanation: Copaxone reduces the rate of relapse in the RR course of MS. It decreases the number of plaques noted on MRI and increases the time between relapses. Copaxone is administered subcutaneously daily. It acts by increasing the antigen-specific suppressor T cells. Side effects and injection site reactions are rare. Copaxone is an option for those with an RR course; however, it may take 6 months for evidence of an immune response to appear.

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.

A client is diagnosed with a brain abscess. Which medication will the nurse anticipate providing to the client? Select all that apply.

Metronidazole Dexamethasone Lacosamide Explanation: A brain abscess is a collection of infectious material within the tissue of the brain. Bacteria are the most common causative organisms. The most common predisposing conditions for abscesses among adults who are immunocompetent are otitis media and rhinosinusitis. Treatment is aimed at controlling increased intracranial pressure (ICP), draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection. It is important for antibiotics such as metronidazole to be started as soon as possible. Corticosteroids such as dexamethasone are used to reduce the cerebral edema caused by inflammation. Anticonvulsants such as lacosamide may be prescribed to prevent or treat seizures. Anticoagulants such as apixaban and opioid analgesics such as hydrocodone are not medications used to treat a brain abscess.

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

Providing palliative care Explanation: vCJD is a progressive fatal disease; no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test Explanation: Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.

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

Vector bites Explanation: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in level of consciousness (LOC), vomiting, and seizures are all symptoms of increased intracranial pressure (ICP) and do not assist in the differentiating of cause, diagnosis, or establishing nursing care.

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" Explanation: Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.

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 Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis 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. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

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." Explanation: The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.

Which is often the most disabling clinical manifestation of multiple sclerosis?

Fatigue Explanation: Fatigue affects 87% of people with MS, and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are other clinical manifestations of MS, but are not the most disabling.

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds Explanation: Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nutrition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.

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. Explanation: 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 nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

Which 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 Explanation: The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

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

Overmedication Explanation: A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy?

Use ophthalmic lubricant and protect the eye. Explanation: The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux(cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?

Vision changes Explanation: Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of MS. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's reflex may be positive. Tremors at rest aren't characteristic of MS; however, intentional tremors (those occurring with purposeful voluntary movement) are common in clients with MS. Affected muscles are spastic, rather than flaccid.

The nurse is assessing a client with sudden bilateral lower extremity weakness and dyskinesia. The client reports accompanying numbness and tingling episodes. Which question will the nurse ask the client to help determine the reason for the client's symptoms?

"Have you had a recent illness?" Explanation: Guillain-Barré syndrome (GBS), also known as acute idiopathic polyneuritis, is an autoimmune attack on the peripheral nerve myelin. An antecedent event (most often a viral infection) precipitates clinical presentation in approximately 60% to 70% of cases. The client should be asked about having a recent illness. GBS is not caused by medication, alcohol, or other illnesses.

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 Explanation: (100 mL/60 minutes) X 15 = 25.

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 Explanation: Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

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. Explanation: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.

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. Explanation: Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

a lower motor neuron lesion. Explanation: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest?

Take small meals of soft consistency Explanation: To help a client with trigeminal neuralgia, who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. The nurse should avoid offering meat and fish in the diet because they require excessive chewing by the client.

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

Herpes simplex virus (HSV) Explanation: HSV-1 ( herpes simplex virus) is the most common cause of acute encephalitis in the United States. Fungal infections of the central nervous system occur rarely in healthy people. The Western equine encephalitis virus is one of four types of arboviral encephalitis that occur in North America is one of several fungi that may cause fungal encephalitis. Lyme disease leads to flu like symptoms and starts as a local infection which can systematically spread causing organ issues, however the incidence is rate, HIV leads to autoimmune disorders.

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 Explanation: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

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 Explanation: Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.

respiratory distress difficulty swallowing Explanation: Respiratory muscles may become paralyzed, requiring endotracheal intubation and mechanical ventilation. If cranial nerve involvement develops, swallowing becomes difficult. Increasing ICP and seizure activity are not expected complications of Guillain-Barré syndrome.

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 Explanation: Tic douloureux (trigeminal neuralgia) is manifested by pain in the areas of the fifth (trigeminal) cranial nerve. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

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 Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

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 Explanation: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. Explanation: Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine and acetaminophen approximately 30 minutes before the administration of amphotericin B may prevent these side effects. Renal toxicity due to amphotericin B is dose limiting. Monitoring serum creatinine and blood urea nitrogen levels may alert the nurse to the development of renal insufficiency and the need to address the clients' renal status. Vascular changes are associated with C. immitis and Aspergillus. Manifestations of vascular change may include arteritis or cerebral infarction. Blood and CSF cultures help diagnosis fungal encephalitis.

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. Explanation: Anger is a defense or response to loss; the nurse should consider that the client is using displacement to deal with emotional pain. Having another nurse care for the patient might send a message to the client that may precipitate feelings of guilt or imply to the client that the nurse no longer wants to provide care. Discontinuing the bath abandons the client and would not encourage expression of feelings. Explaining that the client is getting good care is a defensive response that focuses on the nurse rather than the client.

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. Explanation: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

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. Explanation: Results of studies on Guillain-Barre syndrome indicate that 60% to 75% of clients recover completely.

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

Assessing respiratory effort Explanation: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

Which drug should be available to counteract the effect of edrophonium chloride?

Atropine Explanation: Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.

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 Explanation: Indicators of a cerebellar abscess include occipital headache, ataxia, and nystagmus.

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 Explanation: Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

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 Explanation: 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 positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

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

Pyridostigmine bromide (Mestinon) Explanation: Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.

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. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.