MED SURG CHAPTER 70

Excessive levels of which neurotransmitter has been implicated in amyotrophic lateral sclerosis (ALS)?

Glutamate Explanation: Excessive levels of the neuro-excitatory neurotransmitter glutamate have been implicated in the neurodegenrative diseases such as ALS, Huntington's disease, and the sequelae of strokes.

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?

Respiratory dysfunction Explanation: When a spinal tumor is located in the cervical area, respiratory compromise may occur from postoperative edema. Hemorrhage would be a concern with any surgery. Bowel incontinence and skin breakdown are possible but not specific to cervical spinal tumors.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action?

Turning the client from side to side, using the logroll technique Explanation: To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy. Explanation: The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

The nurse is caring for a client who has been hospitalized for investigation of a sudden change in gait due to loss of balance and coordination. A magnetic resonance imaging scan reveals the client has a brain tumor. On or close to which brain structure is the tumor most likely situated?

Cerebellum Explanation: The cerebellum is the brain structure responsible for balance, coordination and fine muscle control. The tumor is most likely located on or near this brain structure. A tumor located on or near the brain stem would more likely cause changes in autonomic functioning such as blood pressure. The temporal lobe is responsible for language comprehension, behavior, memory, hearing and emotions. A tumor effecting the pituitary gland would result in hormonal changes as this structure is responsible for hormones, growth and reproductive processes in the body.

The nurse is caring for a client who underwent surgery to remove a spinal cord tumor. When conducting the postoperative assessment, the nurse notes the presence of a bulge at the surgical site. The nurse suspects the client is experiencing what complication from the surgery?

Cerebrospinal fluid leakage Explanation: Bulging at the incision may indicate a contained cerebrospinal fluid (CSF) leak. The site should be monitored for increasing bulging, known as pseudomeningocele, which may require surgical repair. Infection at the surgical site should be suspected if the surgical dressing is stained. The bulge does not indicate growth of secondary tumor, this can only be identified using diagnostic imaging. Impaired tissue healing would be indicated if the nurse assessed redness, swelling and warmth at the surgical site during a dressing change. The bulge at the site warrants further assessment of a postsurgical leak of CSF.

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?

Dopamine Explanation: The impaired balance and uncontrolled tremors of Parkinson's disease have been linked with low levels of dopamine. The other neurotransmitters have not been implicated in Parkinson's disease in this manner.

The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer?

Mannitol Explanation: Mannitol is an osmotic diuretic that is administered to decrease the fluid content of the brain, which leads to a decrease in intracranial pressure. Temozolomide is a chemotherapeutic agent which is commonly used to stop or slow cell growth in certain types of brain tumors. Bevacizumab and everolimus are immunotherapy agents that reduce the vascularization of tumors, thereby inhibiting tumor growth.

Which statement indicates appropriate nursing intervention for a client with post-polio syndrome?

Provide care aimed at slowing the loss of strength and maintaining overall well-being. Explanation: No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting clients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well-being of the client. Clients need to plan and coordinate activities to conserve energy and reduce fatigue. Important activities should be planned for the morning as fatigue often increases in the afternoon and evening. Pain in muscles and joints may be a problem. Nonpharmacologic techniques, such as the application of heat and cold, are most appropriate because these clients tend to have strong reactions to medications

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance Explanation: A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period?

Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of his hips and shoulders and eliminates twisting in his operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for?

Suicidal ideations Explanation: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate, but not as important as assessing for suicidal ideations.

The nurse is providing end-of-life care to a client who was diagnosed with glioblastoma multiforme (GBM) 8 months ago. Despite a calm interaction with the client 1 hour ago, the client is now angry and yells, "Get out of my room and don't touch me anymore. I don't need your help!" How should the nurse respond?

"I can tell now is not the right time for me to come in and check on you. Please let me know when it is a better time for me to come back." Explanation: Personality changes, mood swings and irritability can be common manifestations of both growth of the brain tumor and also the process of grief and loss, such as in the case of the client who is receiving end-of-life care. The client's anger and yelling at the nurse is indicative of ineffective coping and warrants the nurse to take a therapeutic approach when responding to the anger. Acknowledging that the client is not ready to receive care at the moment and asking the client to contact the nurse when he or she is ready enables to client to maintain control and promotes self-esteem. Telling the client to speak to the nurse's supervisor does not promote a strong nurse-patient relationship and is not a supportive way to manage end-of-life care. Telling the client that he or she is not permitted to speak to the nurse "that way" may increase the client's anger and puts limits on the client's sense of control. This response does not promote an effective nurse-patient relationship. The nurse must use extra caution when responding to a client who is experiencing emotional swings when faced with death and dying. By stating, "I can see you no longer want me as your nurse," the nurse is making an assumption that the client does not want him or her as the nurse any longer. By making this statement, the nurse is limiting opportunities for the client to verbalize feelings and emotions related to stress, grief and loss.

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

Explaining hospice care and services Explanation: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight. Explanation: A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.

What is the only known risk factor for brain tumors?

Ionizing radiation Explanation: Ionizing radiation is the only known risk factor for brain tumors. Head trauma, use of hair dyes, and the use of cellular phones are possible causes that have been investigated.

A patient is diagnosed with an aggressive, primary malignant brain tumor. The nurse is aware that the glioma:

Originated within the brain tissue. Explanation: The most aggressive type of malignant brain tumor is a glioma, which originates within the brain tissue.

Which term is used to describe edema of the optic nerve?

Papilledema Explanation: Papilledema is edema of the optic nerve. Scotoma is a defect in vision in a specific area in one or both eyes. Lymphedema is the chronic swelling of an extremity due to interrupted lymphatic circulation, typically from an axillary dissection. Angioneurotic edema is a condition characterized by urticaria and diffuse swelling of the deeper layers of the skin.

Which of the following is a late symptom of spinal cord compression?

Paralysis Explanation: Later symptoms include evidence of motor weakness and sensory deficits progressing to paralysis. Early symptoms associated with spinal cord compression include bladder and bowel dysfunction (urinary incontinence or retention; fecal incontinence or constipation).

The nurse teaches the client with which disorder that the disease is due to decreased levels of dopamine in the basal ganglia of the brain?

Parkinson disease Explanation: In some patients, Parkinson disease can be controlled; however, it cannot be cured. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. 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 and fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.

The nurse educator is teaching nursing students about various types of brain tumors. The instructor recognizes that teaching has been effective when students correctly identify a client whose lab work indicates excessively high levels of thyroid stimulating hormone would most likely be diagnosed with which type of tumor?

Pituitary adenoma Explanation: Pituitary adenomas can increased production of several hormones including TSH, ACTH, growth hormone and prolactin. Excessive hormone production is not characteristic of the brain tumors identified in the alternate options.

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that:

Surgery can improve survival time but the results are not guaranteed. Explanation: The overall prognosis for this type of aggressive brain tumor is poor but surgery can improve survival time.

The nurse is seeing a client who is suspected of having a glioblastoma multiforme tumor. The nurse anticipates the client will require which diagnostic test to confirm the client has this form of brain tumor?

Tissue biopsy Explanation: Glioblastoma multiforme is the most common and aggressive malignant brain tumor. In most cases, a tissue biopsy, which can be obtained at the time of surgical removal, is needed to confirm the diagnosis. A Weber and Rinne test may be useful in assessing asymmetric hearing loss associated with an acoustic neuroma, not glioblastoma multiforme. The diagnosis of an angioma is suggested by the presence of another angioma somewhere in the head or by a bruit (an abnormal sound) that is audible over the skull. Functioning pituitary adenoma can produce one or more hormones, normally by the anterior pituitary. Increase maybe seen in prolactin hormone, growth hormone, adrenocorticotropic hormone, or thyroid-stimulating hormone.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG). Explanation: To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalities.

How should the nurse best teach the client admitted with post-polio syndrome about causative pathophysiology?

The exact cause is unknown, but aging or muscle overuse is suspected. Explanation: The exact cause of post-polio syndrome is not known, but researchers suspect that with aging or muscle overuse, the neurons that were not destroyed originally by the poliovirus are unable to continue generating axon sprouts. The exact cause of post-polio syndrome is not known.

The nurse is providing health education to a client recently diagnosed with a brain tumor. During the appointment, the client states, "I'm really worried that I will have a seizure while I am at work or with my kids. Should I be concerned about this?" How should the nurse respond?

"There is a risk for seizures in people who have this diagnosis. What have you already discussed with your primary health care provider regarding management of seizures?" Explanation: In this case, the client is verbalizing a valid concern about management of the potential manifestation of the brain tumor. The nurse should engage the client by providing fact-based information about the probability of seizures caused by effects of brain tumors. The nurse should further engage in the discussion by evaluating the client's existing understanding of the seizures related to brain tumors and the associated management of this problem. The open-ended manner in which the nurse has asked the question in the correct answer option allows the client to reveal any knowledge deficits or gaps in understanding of the condition. Telling the client there is a strong chance that he or she will have a seizure is countertherapeutic and would serve to increase the client's anxiety. The nurse's aim should be to reduce the client's anxiety related to the diagnosis. Telling the client that seizures are a genetic neurological condition is out of context in this situation. The client is worried about having a seizure because he or she has a brain tumor. The nurse should address the concern in the correct context. The nurse is incorrect when stating having this discussion is not within the nurse's scope of practice. The client's verbalized concern presents an opportunity for the nurse to evaluate the client's understanding of the treatment and management of the condition. The nurse should refer the client back to the primary health care provider if there are any aspects of the client's health history that are unclear.

The nurse is providing discharge teaching to a client with a spinal cord tumor and instructs the client to avoid hot water bottles and heating blankets for what reason?

Impaired sensory perception Explanation: Clients with residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be educated about the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters) as their sensory integration may be impaired, causing them to lose the ability to detect dangerous stimulations and to react appropriately. Discharge teaching for motor weakness involves learning different ways to manage activities of daily living and possible teaching regarding the use of assistive devices such as a cane. Medications used in the treatment of spinal tumors would not predispose the client to diminished sensory integration; this problem arises from brain structure and spinal cord compression. Although cognitive impairment may be sequelae resulting from the growth and treatment of brain and spinal tumors, the primary reason clients are instructed not to use excessive temperatures is because they may have lost of ability to sense extremes of hot and cold.

A 55-year-old female client presents at the walk-in clinic complaining of feeling like a mask is on her face. While doing the initial assessment, the nurse notes the demonstration of a pill-rolling movement in the right hand and a stooped posture. Physical examination shows bradykinesia and a shuffling gait. What would the nurse suspect is the causative factor for these symptoms?

Parkinson's disease Explanation: Early signs include stiffness, referred to as rigidity, and tremors of one or both hands, described as pill-rolling (a rhythmic motion of the thumb against the fingers). The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object.Bradykinesia, slowness in performing spontaneous movements, develops. Clients have a masklike expression, stooped posture, hypophonia (low volume of speech), and difficulty swallowing saliva. Weight loss occurs. A shuffling gait is apparent, and the client has difficulty turning or redirecting forward motion. Arms are rigid while walking. These symptoms are not indicative of MS, Myesthenia gravis, or Huntington's.

A client with Parkinson's disease has been receiving levodopa as treatment for the past 7 years. The client comes to the facility for an evaluation and the nurse observes facial grimacing, head bobbing, and smacking movements. The nurse interprets these findings as which of the following?

Dyskinesia Explanation: Most clients within 5 to 10 years of taking levodopa develop a response to the medication called dyskinesia, manifested as facial grimacing, rhythmic jerking movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities. Bradykinesia refers to an overall slowing of active movement and is a manifestation of the disorder. Micrographia refers to the development of small handwriting as dexterity declines with Parkinson's disease. Dysphonia refers to soft, slurred, low-pitched, and less audible speech that occurs as the disorder progresses.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.

The nurse is assessing a client who was brought to the emergency department due to a severe headache with sudden onset, lowered level of consciousness and slurred, non-sensical speech. The client completed chemotherapy and radiation treatment for a glioma-type brain tumor 6 months ago. The client has been taking low molecular weight heparin since completing treatment. The nurse should be prepared to provide care for which possible problem?

Intracerebral hemorrhage Explanation: Clients receiving anticoagulant agents, such as low molecular weight heparin, must be closely monitored because of the risk of central nervous system hemorrhage, also known as an intercerebral hemorrhage. Both deep vein thrombosis and pulmonary embolism would be prevented or mitigated by the use of anticoagulant medications such as low molecular weight heparin. The nurse should always consider the risk of these latter problems, however, because the client is clearly at risk for impaired coagulation. Spinal metastasis can result in spinal cord compression, which is considered a medical emergency requiring immediate treatment. In this case, the nurse would observe reports of back pain, extremity weakness, ataxia and/or paralysis.

Bone density testing in clients with post-polio syndrome has demonstrated

low bone mass and osteoporosis. Explanation: Bone density testing in clients with post-polio syndrome has demonstrated low bone mass and osteoporosis. Thus, the importance of identifying risks, preventing falls, and treating osteoporosis must be discussed with clients and their families.

The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse?

"If one parent has the disorder, there is a 50% chance that you will inherit the disease." Explanation: Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. The disease affects approximately 1 in 10,000 men or women of all races at midlife. It is transmitted as an autosomal dominant genetic disorder; therefore, each child of a parent with Huntington disease has a 50% risk of inheriting the disorder

The nursing instructor gives their students an assignment of making a plan of care for a client with Huntington's 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 Explanation: The nurse demonstrates how to facilitate tasks such as using both hands to hold a drinking glass, using a straw to drink, and wearing slip-on shoes. The teaching portion of the care plan would not include how to exercise, perform household tasks, or take a bath.

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches?

Increased intracranial pressure Explanation: Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor, leading to increased intracranial pressure.

The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan?

Knowledge deficit Explanation: Clients with extensive neurologic deficits before surgery usually do not make significant functional recovery, even after successful tumor removal. In this case, the client had already developed bilateral sensory loss in the lower extremities indicating the fairly progressed impact of the tumor on the client's functional ability. The client's statement reflects a knowledge deficit and it is a priority to provide information regarding the possibility that lower extremity sensation may not return. Although body image disturbance and anxiety may be identified and addressed. This would occur after the client demonstrates an accurate understanding of loss of functional capabilities as a result of the progressed tumor. Ensuring the client understands the extent of functional loss due to the impact of the tumor is a priority. The client does not demonstrate impaired cognition.

The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?

Rapid, jerky, involuntary movements Explanation: The most prominent clinical features of the disease are chorea (rapid, jerky, involuntary, purposeless movements), impaired voluntary movement, intellectual decline, and often personality changes

Which statement(s) reflect nursing interventions for a client with post-polio syndrome?

The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client Explanation: No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting clients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client. Clientss need to plan and coordinate activities to conserve energy and reduce fatigue. Important activities should be planned for the morning as fatigue often increases in the afternoon and evening. Pain in muscles and joints may be a problem. Nonpharmacologic techniques such as the application of heat and cold are most appropriate because these clients tend to have strong reactions to medications.

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease?

Maintaining a safe environment Explanation: The primary focus in caring for Parkinson's disease is on maintaining a safe environment. Parkinson's disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.