PEPU TEST 5
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: a) carefully move the client to a flat surface and turn him on his side. b) place an oral airway in the client's mouth to maintain an open airway. c) hold the client's arm still to keep him from hitting anything. d) allow the client to remain in the chair but move all objects out of his way.
A
Low levels of the neurotransmitter serotonin lead to which of the following disease processes? a) Depression b) Seizures c) Parkinson's disease d) Myasthenia gravis
A A decrease of serotonin leads to depression. A decrease in the amount of acetylcholine causes myasthenia gravis. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? a) Diplopia and ptosis b) Numbness c) Patchy blindness d) Loss of proprioception
A, The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.
The most common cause of cholinergic crisis includes which of the following? a) Overmedication b) Infection c) Compliance with medication d) Undermedication
A, 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. (
One defining characteristic of a complex partial seizure versus a simple partial seizure is the presence of which of the following? a) Impaired consciousness b) Motor symptoms c) Sensory symptoms d) Compound forms
A, A complex partial seizure is characterized by complex symptoms with the impairment of consciousness. A simple partial seizure generally occurs without impairment of consciousness.
A patient has difficulty interpreting his awareness of body position in space. Which lobe is most likely to be damaged? a) Parietal b) Occipital c) Temporal d) Frontal
A, The parietal lobe is the primary sensory cortex. It is essential to a person's awareness of his body in space, as well as orientation in space and spatial relations.
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a) Bradycardia b) Lethargy and stupor c) A bounding pulse d) Hypertension
B, As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required
Which of the following is one of the earliest signs of increased ICP? a) Lethargy b) Decreased level of consciousness (LOC) c) Headache d) Coma
B, Decreasing LOC is one of the earliest signs of increased ICP.
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? a) "You'll first regain use of your legs and then your arms." b) "You'll be permanently paralyzed; however, you won't have any sensory loss." c) "The paralysis caused by this disease is temporary." d) "It must be hard to accept the permanency of your paralysis."
C, 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.
Upper motor neuron lesions cause a) flaccid paralysis. b) absent or decreased reflexes. c) no muscle atrophy. d) decreased muscle tone.
C,Upper motor neuron lesions do not cause muscle atrophy but do cause loss of voluntary control. Lower motor neuron lesions cause decreased muscle tone. Lower motor neuron lesions cause flaccid paralysis. Lower motor neuron lesions cause absent or decreased reflexes
The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart? a) CN I b) CN IV c) CN III d) CN II
D, The nurse assesses vision and thus the optic nerve (cranial nerve II) by use of a Snellen eye chart.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a) decreasing blood pressure. b) elevated temperature. c) pupillary changes. d) diminished responsiveness.
D, Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a) Give the patient some mouthwash to gargle with. b) Request an antihistamine for the postnasal drip. c) Ask the patient to cough to observe the sputum color and consistency. d) Notify the physician of a possible cerebrospinal fluid leak.
D,Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by cerebrospinal fluid trickling down the throat.
To meet the sensory needs of a client with viral meningitis, which of the following should the nurse do? Choose the correct option. a) Avoid physical contact with family members b) Promote an active range of motion c) Minimize exposure to bright lights and noise d) Increase environmental stimuli
C, Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment having less stressful stimuli to such clients.
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a) Infection b) Increase in cerebral perfusion pressure c) Increased ICP d) Exacerbation of uncontrolled hypertension
C,Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP.
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) A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" b) A disorder in which histocompatible cells attack the immunoglobulins c) A disorder in which the body does not have enough immunoglobulins d) A disorder in which the body has too many immunoglobulins
A, 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.
A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a) More than 200 mL/h b) 50 to 100 mL/h c) 150 to 200 mL/h d) 100 to 150 mL/h
A, For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus (Hickey, 2009).
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? a) Antibodies are removed from the plasma. b) Mestinon therapy is initiated. c) Immune globulin is given intravenously. d) The thymus gland is removed.
A, 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
During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates: a) cranial nerves I and II. b) cranial nerves IX and X. c) cranial nerves III and V. d) cranial nerves VI and VIII.
B, Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.
A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain? a) VI b) V c) III d) IV
B, The trigeminal nerve (cranial nerve V) innervates the forehead, cheeks, and jaw, so pain in the face elicited when brushing the teeth would most likely involve this nerve.
Which lobe of the brain is responsible for concentration and abstract thought? a) Occipital b) Parietal c) Frontal d) Temporal
C, The major functions of the frontal lobe are concentration, abstract thought, information storage or memory, and motor function. The parietal lobe analyzes sensory information such as pressure, vibration, pain, and temperature. The occipital lobe is the primary visual cortex. The temporal lobe contains the auditory receptive areas located around the temples.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? a) "Limit your fruit and vegetable intake." b) "Avoid taking daytime naps." c) "Avoid hot baths and showers." d) "Restrict fluid intake to 1,500 ml/day."
C, The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.
Bell's palsy is a disorder of which cranial nerve? a) Vagus (X) b) Trigeminal (V) c) Vestibulocochlear (VIII) d) Facial (VII)
Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Mnire's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barr syndrome is a disorder of the vagus nerve.
Lower motor neuron lesions cause a) no muscle atrophy. b) hyperactive and abnormal reflexes. c) flaccid muscle paralysis. d) increased muscle tone.
C, Lower motor neuron lesions cause flaccid muscle paralysis, muscle atrophy, decreased muscle tone, and loss of voluntary control. Upper motor neuron lesions cause increased muscle tone. Upper motor neuron lesions cause no muscle atrophy. Upper motor neuron lesions cause hyperactive and abnormal reflexes.
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? a) Multiple sclerosis b) Creutzfeldt-Jakob disease c) Huntington disease d) Parkinson's disease
A, The cause of MS is not known and the disease affects twice as many women as men. Parkinson's 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.
In the divisions of the nervous systems, the basic structure is the neuron. The function of the neuron is determined by the direction of impulse transmission. Which part of the neuron is responsible for conducting impulses away from the cell body? a) Nucleus b) Dendrite c) Efferent nerve fibers d) Afferent nerve fibers
C, An axon is a nerve fiber that projects and conducts impulses away from the cell body. It is therefore called an efferent ("away from") nerve fiber
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? a) Place the patient in the supine position. b) Administer diphenhydramine (Benadryl) for the allergic reaction. c) Call the rapid response team because the patient is preparing to arrest. d) Administer atropine to control the side effects of edrophonium.
D, Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.
Which of the following is considered a central nervous system (CNS) disorder? a) Myasthenia gravis b) Guillain-Barré c) Bell's palsy d) Multiple sclerosis
D, 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 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? a) Carbachol (Carboptic) b) Edrophonium (Tensilon) c) Ambenonium (Mytelase) d) Pyridostigmine (Mestinon)
B, 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.
A 53-year-old man presents to the emergency department with a chief complaint of inability to form words, and numbness and weakness of the right arm and leg. Where would you locate the site of injury? a) Left basal ganglia b) Left frontoparietal region c) Left temporal region d) Right frontoparietal region
B, The patient is exhibiting signs of expressive aphasia with numbness/tingling and weakness of the right arm and leg. This indicates injury to the expressive speech center (Broca's area), which is located in the inferior portion of the frontal lobe. The motor strip is located in the posterior portion of the frontal lobe. The sensory strip is located in the anterior parietal lobe.
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a) Low in fat b) High in protein and low in carbohydrate c) Restricts protein to 10% of daily caloric intake d) At least 50% carbohydrate
B, A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients. This high-protein, low-carbohydrate, high-fat diet is most effective in children whose seizures have not been controlled with two antiseizure medications, but it is sometimes used for adults who have had poor seizure control (Mosek, Natour, Neufeld, et al., 2009).
What drug, prescribed for Parkinson's disease, has neuroprotective properties? a) Amantadine (Symmetrel) b) Selegiline (Eldepryl) c) Levodopa (Larodopa) d) Bromocriptine (Parlodel)
B, Selegiline (Eldepryl), has neuroprotective properties; dopaminergics such as levodopa (Larodopa) or levodopa-carbidopa (Sinemet); amantadine (Symmetrel); dopamine agonists such as bromocriptine (Parlodel); apomorphine (Apokyn), the newest approved drug; and anticholinergics such as benztropine (Cogentin) are prescribed.
Ada Zontor, a 60-year-old bookkeeper, is a client with the neurological group where you practice nursing. Mrs. Zontor has been exhibiting neurological symptoms for several weeks and the neurologist is admitting her to hospital for extensive testing. Since diagnostics have not yet revealed the cause of her difficulties, which of her following comments would indicate the need for further client education? a) There are several types of tests to see what's causing the tingling in my fingers and toes. b) All of her comments indicate need for further client education. c) It's good to know the continual tingling in my fingers and toes is not connected with my nervous system! d) I need to be careful with my allergy to seafood!
C, The nervous system consists of the brain, spinal cord, and peripheral nerves.
A nurse is preparing a client for lumbar puncture. The client has heard about post-lumbar puncture headaches and asks how to avoid having one. The nurse tells the client that these headches can be avoided by doing which of the following after the procedure? a) "Remain NPO for 6 hours." b) "Ambulate as soon as possible." c) "Remain prone for 2 to 3 hours." d) "Remain on bedrest for 3 days."
C,The headache is caused by cerebral spinal fluid (CSF) leakage at the puncture site. The supply of CSF in the cranium is depleted so that there is not enough to cushion and stabilize the brain. When the client assumes an upright position, tension and stretching of the venous sinuses and pain-sensitive structures occur. The headache may be avoided if the client remains prone for 2 to 3 hours after the procedure. Drinking plenty of fluids will help in replacing the CSF. Hydration is important for replacement of the CSF lost so remaining NPO is not an option unless it is for other reasons, then IV fluid replacement will be important. Ambulating right away will make the possibility of a headache more likely. It is not necessary to remain on bedrest for more than a few hours, unless a headache has occurred; then bedest for overnight is usually sufficient
Working hard to memorize the functions of the cranial nerves is a typical part of nursing school. Not only is it important to correlate the proper nerve number and name, but including the proper function makes this task quite a challenge! Which cranial nerves are enabling you to read this question? a) Oculomotor b) Abducens c) Trochlear d) All options are correct
D,The Oculomotor (III), Abducens (VI) and Trochlear (IV) nerves all work within the functional realm of the eyes. Don't forget the Optic (II) nerve!
A high school soccer player sustained five concussions before she was told that she should never play contact sports again. After her last injury, she began experiencing episodes of double vision. She was told that she had most likely incurred damage to which cranial nerve? a) V (Trigeminal) b) VI (Abducens) c) IV (Trochlear) d) VII (Facial)
B, The abducens cranial nerve supports movement of the eye laterally. Damage to the nerve can cause double vision.
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? a) 50 mm Hg b) 60 mm Hg c) 70 mm Hg d) 80 mm Hg
C, Changes in ICP are closely linked with cerebral perfusion pressure (CPP). The CPP is calculated by subtracting the ICP from the mean arterial pressure (MAP). For example, if the MAP is 100 mm Hg and the ICP is 15 mm Hg, then the CPP is 85 mm Hg. The normal CPP is 70 to 100 mm Hg (Hickey, 2009)
The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve? a) CN III b) CN II c) CN I d) CN IV
C, Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.
A client newly diagnosed with multiple sclerosis (MS) asks about a cure for her disease process. The nurse gives which of the following information? a) Medications do not assist with relief of signs and symptoms. b) If recommendations for symptom relief are followed, the disease will be cured. c) There is no cure for MS. d) Life expectancy for clients with MS is dramatically different from that of those without MS.
C, No cure exists for MS. Life expectancy for clients with MS is not dramatically different from that of clients without MS. Medications are available for symptom management of clients with MS
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? a) Disabling b) Primary progressive c) Relapsing-remitting (RR) d) Benign
C, Approximately 85% of patients with MS have a relapsing-remitting (RR) course. With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline.
What part of the brain controls and coordinates muscle movement? a) Cerebellum b) Cerebrum c) Midbrain d) Brain stem
A, The cerebellum, which is located behind and below the cerebrum, controls and coordinates muscle movement. Options B, C ,and D are incorrect
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: a) rest in an air-conditioned room. b) avoid naps during the day. c) take a hot bath. d) increase the dose of muscle relaxants.
A,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.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? a) Alternatively patch one eye every 2 hours. b) Encourage the client to close his eyes. c) Instill artificial tears. d) Turn out the lights in the room.
A,Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia
The critical care nurse is giving report on a client they are caring for. The nurse uses the Glasgow Coma Scale (GCS) to assess the level of consciousness (LOC) of a female client and reports to the on-coming nurse that the client has an LOC of 6. What does an LOC score of 6 in a client indicate? a) Stupor b) Somnolence c) Normal d) Comatose
D, The GSC is used to measure the LOC. The scale consists of three parts: eye opening response, best verbal response, and best motor response. A normal response is 15. A score of 7 or less is considered comatose. Therefore, a score of 6 indicates the client is in a state of coma, and not in any other state such as stupor or somnolence. The evaluations are recorded on a graphic sheet where connecting lines show an increase or decrease in the LOC
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? a) Tell the patient to smile every 4 hours. b) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. c) Inform the patient that the muscle function will return as soon as the virus dissipates. d) Suggest applying cool compresses on the face several times a day to tighten the muscles.
B, 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
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a) Anemia b) Osteoporosis c) Obesity d) Osteoarthritis
B, Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
The Family Nurse Practitioner is performing the physical examination of a client with a suspected neurologic disorder. In addition to assessing other parts of the body, the nurse should assess for neck rigidity. Which method should help the nurse assess for neck rigidity correctly? a) Gently pressing the bones on the neck b) Moving the head and chin toward the chest c) Moving the head toward both sides d) Lightly tapping the lower portion of the neck to detect sensation
B, The neck is examined for stiffness or abnormal position. The presence of rigidity is assessed by moving the head and chin toward the chest. The nurse should not maneuver the neck if a head or neck injury is suspected or known. The neck should also not be maneuvered if trauma to any part of the body is evident. Moving the head toward the sides or pressing the bones on the neck will not help assess for neck rigidity correctly. While assessing for neck rigidity, sensation at the neck area is not to be assessed
The sympathetic and parasympathetic nervous systems have a direct affect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? a) Blood vessels in the heart muscle to dilate b) Heartbeat to decrease c) Blood pressure to increase d) Blood vessels in the skeletal muscles to dilate
B,The parasympathetic nervous system has a constricting effect on the blood vessels in the heart and skeletal muscles; the heartbeat and blood pressure will decrease
A client, suspected of having a distortion of cerebral arteries and veins, is scheduled for a cerebral angiography. What would the nurse tell the client about the upcoming test? a) That sedatives, coffee, tea, and soft drinks that contain caffeine will be withheld for at least 8 hours before the test to avoid affecting the diagnostic findings. b) The client will have to stay in a dark quiet room. c) Contrast will be given and a rapid sequence of radiographs will be taken. d) The client will have to shampoo his or her hair.
C, A radiopaque dye is injected into the right or left carotid artery, the brachial artery, or the femoral artery. A rapid sequence of radiographs is taken as the dye circulates through the cerebral arteries and veins. For cerebral angiography options A, B, and D do not apply.
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a) 9 b) 3 c) 12 d) 6
B, LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68)
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? a) Computed tomography (CT) scan b) Tensilon test c) Electromyogram (EMG) d) Serum studies
B, 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 nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? (Select all that apply.) a) Allow the patient adequate time to perform exercises b) Demonstrate daily muscle stretching exercises. c) Assist with a rigorous exercise program to prevent contractures. d) Have the patient take a hot tub bath to allow muscle relaxation. e) Apply warm compresses to the affected areas.
A,B,E Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.
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? a) Within 72 hours after exposure b) Within 24 hours after exposure c) Within 48 hours after exposure d) Therapy is not necessary prophylactically and should only be used if the person develops symptoms.
B, 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 is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? a) The type of anticonvulsant prescribed to manage the epileptic condition b) Compliance with the prescribed medication regimen c) Recent weight gain and loss d) Recent stress level
B, The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.