Quiz: Chapter 53, Care of the Patient with a Neurologic Disorder

The nurse is repeating instructions regarding techniques to avoid fatigue to a patient with multiple sclerosis. What instructions does the nurse include in the teaching?

Rest in air-conditioned surroundings. The nurse instructs the patient to plan rest periods in an air-conditioned room to prevent fatigue. Cool environments reduce stress and prevent fatigue. The patient should avoid hot baths, as they may increase muscle weakness. Patients with multiple sclerosis are instructed to take naps during the daytime to relax. Muscle relaxants are prescribed to patients who have disturbed muscle tone, as in the case of cerebral palsy. Muscle tone is not disturbed in multiple sclerosis.

A patient with a seizure disorder is admitted to the health care facility. What action can a registered nurse (RN) delegate to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)?

Review the patient's plan of care. The LPN/LVN can participate in planning, reviewing, and revising the patient's plan of care. The LPN/LVN develops the patient's plan of care according to the patient's needs to provide effective care. The registered nurse (RN) should perform the complete initial assessment. Tongue blades should not be placed at the bedside and should never be inserted into the patient's mouth once the seizure begins. Side rails are padded after the patient is placed in the bed, to provide safety.

A patient with chronic migraines would like to explore preventive therapy. The nurse anticipates which medication will be prescribed?

Topiramate (Topamax). Topiramate (Topamax) is taken daily to prevent headaches. Ergotamine, Imitrex, and aspirin are taken once the migraine appears.

Which statement does the nurse include while teaching the family members of a patient who is diagnosed with Stage 1 Alzheimer disease (AD)?

Patients will be unable to communicate through writing in the third stage. Patients in the third stage of Alzheimer's disease (AD) lose the ability to communicate through writing and become incontinent, indifferent to food, and lose weight. Patients find difficulty in recognizing their family, friends, or even themselves. Sundowning begins in the second stage, not the third stage. Incontinence is observed in the third stage, not the second stage. The average life expectancy is 1 to 2 years from the onset of the third stage, not the second stage.

What should the nurse do while preparing a patient suspected of having a brain tumor for a computer tomography (CT) scan of the brain?

Determine whether the patient is allergic to iodine. A CT scan involves the use of iodine dye in the contrast medium. Before performing the CT scan, the nurse should determine whether the patient is allergic to iodine. Immobilize the patient only if the patient has any spinal injury. The nurse should not place a cap on the patient's head, as it interferes with the test. Sedatives are not necessary, as the procedure is painless except for the intravenous injection of the dye.

A nurse caring for a patient newly diagnosed with myasthenia gravis anticipates administering which medication?

Neostigmine (Prostigmin). The nurse would anticipate administering neostigmine (Prostigmin), an acetylcholinesterase inhibitor, to the patient with myasthenia gravis. Digoxin, phenytoin, and carbidopa-levodopa are not used to treat myasthenia gravis.

The parent of a child newly diagnosed with a typical absence seizure is worried. What information should the nurse provide to the parent regarding typical absence seizures? Select all that apply.

The seizures are characterized by brief staring spells. The seizures are usually precipitated by flashing lights. The occurrence of seizures usually subsides during adolescence. The typical absence seizure usually occurs in childhood only, and the occurrences subside in adolescence. The seizures are characterized by brief staring spells that last for a few seconds only. Flashing lights tend to precipitate a seizure. The child may not have loss of postural tone and may not experience confusion after a seizure.

A patient with Parkinson disease is unresponsive to drug therapy and is being considered for surgery. What surgical options should the nurse expect the doctor to discuss with the patient and the caregivers to help in decision making? Select all that apply.

Ablation Transplantation Deep brain stimulation The surgical therapies for Parkinson disease include ablation, deep brain stimulation, and transplantation. Ablation surgery involves stereotactic ablation of areas in the thalamus, globus pallidus, and subthalamic nucleus. Deep brain stimulation involves placing an electrode in the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest. The device is programmed to deliver a specific current to the targeted brain location. Transplantation of fetal neural tissue into the basal ganglia is designed to provide dopamine-producing cells in the brain. Thymectomy is used in the treatment of myasthenia gravis. Dorsal-column electrical stimulation helps in minimizing symptoms of multiple sclerosis.

What term most accurately describes age-related changes of the neurologic system?

As neurons are lost with aging, there is deterioration in neurologic function. As neurons are lost with aging, there is deterioration in neurologic function, resulting in slowed reflexes and reaction time. Becoming senile is not an inevitable consequence of aging. The incidence of physiologic dementia or organic brain syndrome increases with age. Older people possess the ability to learn, but the speed of learning is slowed with age. In performing patient teaching, the nurse needs to allow adequate time for the older adult. Short-term memory is more affected by aging than is long-term memory.

The nurse is caring for a patient with Parkinson disease. What adjustments should the nurse make in the dietary habits of the patient to prevent malnutrition and constipation? Select all that apply.

Cut food into bite-size pieces. Serve hot foods on a warmed plate. Include whole grains and fruits in the diet. Patients with Parkinson disease are predisposed to malnutrition and constipation, owing to inadequate food intake caused by difficulty in chewing and swallowing. To promote adequate nutrition, the nurse should include whole grains and fruits in the diet, which will prevent constipation. The food should be cut into bite size pieces so that chewing and swallowing is easy. Serving hot foods on a warmed plate makes the food more appealing. Food items high in protein should be limited in the diet, because they can interfere with the absorption of carbidopa-levodopa (Sinemet), the most common drug used in the treatment of Parkinson disease. Six small meals, rather than three large meals, would be less exhausting for the patients.

A patient is advised to use diazepam (Valium) for multiple sclerosis. What patient teaching is important for those taking this drug? Select all that apply.

Do not stop the drug abruptly. Avoid driving while on the drug. Avoid taking alcohol with the drug. Diazepam (Valium) is used as a muscle relaxant. Patients on diazepam should avoid driving and any such activities requiring the patient to be alert, because of the sedative effects of the drug. They should not stop the drug abruptly without consulting the health care provider. The drug should not be taken along with alcohol, because alcohol can potentiate the drug's effect. Monitoring blood pressure is a general healthcare measure and is not specific to diazepam. As the drug has no effect on the immune system, avoiding crowds is not necessary.

A patient diagnosed with seizures is advised to take phenytoin (Dilantin). Which common side effects of phenytoin (Dilantin) should the nurse inform the patient about?

Gingival hyperplasia Gingival hyperplasia is the most common side effects of phenytoin. Good dental hygiene, including regular tooth brushing and flossing, can limit gingival hyperplasia. The drug is not associated with neuropathy, memory loss, or weight gain.

The caregivers of a patient with acute seizures ask the nurse what they should do if another episode of seizure occurs at home after discharge. What should the nurse tell them? Select all that apply.

Loosen constrictive clothes. Ease the patient to the floor. Protect the patient from any injury. During an acute seizure, the most important thing is to ease the patient to the floor, if seated, and loosen constrictive clothing. The patient should be protected from any potential injury. The chances of injury are higher if the patient is restrained. It is not necessary to bring the patient to the hospital immediately. Once the seizures have stopped and the patient becomes stable, then the patient can be brought to the hospital.

A patient is going for a diagnostic test. The nurse listens as the primary health care provider explains the procedure to the patient. The primary health care provider states that the test involves the use of differential signal characteristics of flowing blood to evaluate extracranial and intracranial blood vessels. In preparing to answer the patient's questions further, what diagnostic test will the nurse address?

Magnetic resonance angiography (MRA) MRA involves the use of differential signal characteristics of flowing blood to evaluate extracranial and intracranial blood vessels. It provides both anatomic and hemodynamic information and can be done with or without contrast media. This test is rapidly replacing cerebral angiography for use in diagnosing cerebrovascular diseases. Cerebral angiography (angiogram) is a procedure used to visualize the cerebral arterial system by injecting radiopaque material. It allows the detection of arterial aneurysms, vessel abnormalities, and displacement of vessels by tumors or masses. A CT scan, also known as a CAT scan, is performed to detect pathologic conditions of the cerebrum and spinal cord through use of a technique of scanning without radioisotopes. The patient must lie still during the procedure; it may be done with or without contrast. MRI uses magnetic forces to image body structures. Compared with a CT scan, it provides better images of soft-tissue structures. It is useful in detecting strokes, multiple sclerosis, tumors, trauma, herniation, and seizures.

What is the autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain muscle groups?

Myasthenia gravis. The autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain muscle groups is myasthenia gravis. It is an unpredictable neuromuscular disease with lower motor neuron characteristics. Although there is no observable structural change in the muscle or nerve, nerve impulses fail to pass at the myoneural junction, resulting in muscle weakness. ALS is a rare, progressive neurologic disease characterized by loss of motor neurons in the brain stem and spinal cord. It usually results in death within 2 to 6 years of onset. Primary symptoms are upper extremity weakness, dysarthria, and dysphagia. There is no cure for ALS. Huntington disease is a genetically transmitted, autosomal dominant disorder that affects men and women of all races. It involves an overactivity of the dopamine pathway, resulting in abnormal and excessive involuntary movements (chorea). Also, there is deterioration in mental processes, including intellectual decline, emotional lability, and psychotic behavior. There is no cure, and death usually occurs 10 to 20 years after the onset of symptoms. Trigeminal neuralgia is a disorder of cranial nerve 5 (the trigeminal nerve), caused by pressure on the nerve or degeneration as a result of unknown factors. It is characterized by excruciating, knifelike pain in the lips, upper or lower gums, cheek, forehead, or side of the nose.

A patient reports difficulty seeing objects at a distance. Which condition is likely to be found in the patient?

Myopia The patient's symptom indicates that the patient has myopia. Myopia is a condition of nearsightedness in which the eyeball gets elongated. Myopia causes refraction errors, so parallel rays are focused in front of the retina. This results in difficulty seeing objects at a distance. In hyperopia the patient is unable to see objects at a close range. Strabismus is a condition in which the patient's eyeballs are not symmetrical and have difficulty following objects visually. In this condition only one eye is able to track a moving object. Astigmatism causes blurring of vision, difficulty in focusing on objects, and eye discomfort.

The results of a patient's cerebrospinal fluid (CSF) examination reveal seven lymphocytes per milliliter of CSF. The nurse knows this patient likely has which type of infection?

None, the lymphocytes are within normal limits. CSF with more than 10 lymphocytes per milliliter of CSF indicates a viral, fungal, or bacterial infection. However, this patient has seven lymphocytes per milliliter of CSF, which is not indicative of an infection.

A nurse is taking care of a patient who suddenly begins to have a seizure. What is the appropriate nursing response?

Observe and record the seizure activity. The primary goals of the nurse caring for a patient having a seizure are to (1) protect from aspiration and injury, and (2) observe and record the seizure activity. Diagnosis and subsequent treatment of a patient with a seizure disorder are often based on the description of the seizure activity. All aspects of the seizure should be recorded: preceding events, length of each phase, what occurred during each phase, and so on. The patient having a seizure should never be left alone. The nurse taking care of a patient having a seizure should not pry the jaw open to place a padded tongue blade into the patient's mouth. The patient having a seizure should not be restrained, with soft restraints or otherwise. Restraints will increase the patient's chances of becoming injured during the seizure.

Which nursing concern should be the highest priority for a patient experiencing a migraine headache?

Pain related to biologic and chemical factors. In a patient with migraine headaches, pain management is the highest priority when compared to other complications. The nurse should diagnose the underlying cause of pain and take measures to prevent it. Diagnosing the potential side effects of medical therapy is justified, but is not of higher priority when compared to pain management. Identifying the patient's anxiety related to his or her health status is also a justified concern, but is not of the highest priority. The nurse should address the patient's hopelessness only after providing pain management.

The nurse is caring for a patient with increased intracranial pressure (ICP). The nurse finds that the patient has an ineffective breathing pattern and a sustained ICP elevation. What interventions should the nurse perform in order to ensure the safety of the patient? Select all that apply.

Perform suctioning for no longer than 10 seconds. Administer 100% oxygen before and after suctioning. Perform a neurologic check using Glasgow Coma Scale. Increased intracranial pressure is a complication seen in most neurologic disorders and may lead to death if not rapidly reversed. Ineffective breathing can be reversed by suctioning the patient's oropharynx for not more than 10 seconds. One hundred percent oxygen is administered to the patient via mask or cannula to prevent the decrease in PaO2 and to improve cerebral perfusion. The nurse should assess the level of consciousness every 30 minutes, using the Glasgow Coma Scale, to find out the patient's neurologic status. The nurse should restrict fluid intake, as increased fluid intake will increase the ICP. A hyperthermia blanket should not be used, as it will increase the body temperature, which further increases the brain damage. The nurse should not make the patient lie in a semi-prone or prone position, as this may lead to an increased ICP. Enemas and laxatives should not be given to the patient.

The nurse will implement which of these nursing interventions for the patient with increased intracranial pressure? Select all that apply.

Place neck in neutral position Teach patient to avoid Valsalva maneuver Position patient to avoid flexion of hips, waist, and neck Suction only as necessary, but no longer than 10 seconds The neck of a patient with increased intracranial pressure must be kept in a neutral position to promote venous drainage. It should not be flexed or extended. The patient should be instructed to avoid the Valsalva maneuver. This needs to be explained to the patient in terms that he or she can easily understand. The patient needs to be positioned in such a way that the hips, waist, and neck are not flexed. Rotation of the head, especially to the right, also must be avoided. Extreme hip flexion causes an increase in intraabdominal and intrathoracic pressure, which can trigger a rise in intracranial pressure. The patient must be suctioned only when absolutely necessary (and for no longer than 10 seconds) because this can increase the intracranial pressure of the patient. In addition, the patient should be hyperoxygenated with 100% oxygen before and after suctioning to prevent a decrease in Pao2. The head of the bed of a patient with increased intracranial pressure needs to be kept at 30 to 45 degrees, which promotes venous return. The patient with increased intracranial pressure will be on fluid restriction.

The nurse educator is teaching a group of student nurses about the safety needs of a paralyzed patient. Which statement made by one of the student nurses indicates the need for further teaching? Select all that apply.

Restrict the patient from turning and repositioning themselves. Do not encourage the patient to perform passive range-of-motion (ROM) exercises. Paralyzed patients should be repositioned frequently, as they are at risk for skin impairment. Making the patients reposition themselves makes them independent to some extent. The nurse should encourage and assist the patient to perform passive or active ROM exercises according to the patient's motor abilities. These exercises promote the reversal of motor impairment. Using supportive devices like braces and splints may prevent the risk of foot drop. As the paralyzed patient lies in the same position for extended periods, the skin over the bony prominences should be checked for signs of pressure. As the patient is unaware of the harm done to the paralyzed parts, the nurse should regularly inspect them for any injuries. If possible, the nurse should provide the patient with a mirror to facilitate self-check by the patient. The nurse should encourage the patient to take small bites and add thickeners to liquid foods in order to prevent choking.

A nurse is caring for a patient with a risk for increased intracranial pressure (ICP). This patient should remain in which position?

Semi-Fowler. The patient should be placed in the semi-Fowler position to elevate the head and allow gravity to prevent increases in ICP. Prone and supine positions allow gravity to increase the ICP. The patient should not change position often.

What should be the immediate nursing intervention to ensure the safety of a patient with tonic-clonic seizures?

Take measures to prevent head injury. When a patient has tonic-clonic seizures, the nurse should immediately take measures to prevent head injury. This measure will prevent further complications related to the seizure. Placing a tongue blade in the patient's mouth causes injury to the teeth. Restraining the patient's arms and legs will cause injury and worsen the patient's condition. Elevating the head of the bed is concerned with the safety of those patients with increased intracranial pressure.

A patient who has multiple sclerosis is prescribed baclofen (Lioresal). On examining the medical history, the nurse finds that the patient has a record of epilepsy. What should the nurse do to ensure the safe and effective therapy of the patient? Select all that apply.

Watch for an increased incidence of epileptic seizures in the patient. Administer the oral form of the drug, either with meals or with milk. Baclofen (Lioresal) is used to treat spinal spasticity in multiple sclerosis and spinal cord injuries. When given to patients with epilepsy, there may be increased incidences of seizures; the nurse must therefore, monitor the patient for the increased incidence of seizures. The oral form of baclofen (Lioresal) should be administered with meals or milk in order to prevent gastrointestinal distress. Patients taking artane (trihexphenidyl hydrochloride) are instructed to relieve dry mouth using cool drinks and ice chips. Administration of baclofen (Lioresal) is unrelated to the occurrence of dry mouth. The patients who are administered symmetrel (amantadine hydrochloride) are instructed not to stand or change positions too quickly. Patients administered artane (trihexphenidyl hydrochloride), should not ingest antacids and antidiarrheal agents within 1 hour of its administration. The timing of antacid administration is unrelated to the administration of baclofen (Lioresal).

A nurse is supervising the care of a patient with multiple sclerosis (MS) by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately

Preparing to place the patient in a bathtub with hot water. Hot water and hot ambient temperatures can lead to muscle weakness. The patient should be encouraged to perform light exercise, rest frequently, and remain in a cool environment.

A nurse enters the room of a patient in bed who appears to be having a seizure. What should the nurse do first?

Turn the patient's head to the side to protect the patient's airway. The nurse should attempt to turn the patient's head to the side to protect the patient's airway. The nurse should not lower the patient who is already in bed to the floor. If the patient is standing or seated, it would be appropriate to lower the patient to the floor. The nurse should never attempt to insert anything into the patient's mouth. Attempts to restrain the patient's limbs could result in injury to the patient or the nurse.

The nurse is repeating instructions to an epileptic patient about the care to be taken after discharge. Which statement made by the patient indicates the need for further teaching?

"I can use many over-the-counter (OTC) medications." A patient with a seizure disorder should not take over-the-counter medications without consulting the primary health care provider. The nurse should warn the patient about the use of OTC medications. The patient is advised to maintain meticulous oral hygiene to prevent edematous and enlarged gums: a side effect of Dilantin (phenytoin) therapy. The patient should not drink anything with alcohol, as it can interfere with the anticonvulsant medications. The patient should be instructed to wear a medical alert bracelet at all times.

The nurse teaches a patient about magnetic resonance imaging (MRI). Which statement should the nurse include in the teaching?

"You should remove any metal from your body or clothing." Magnetic resonance imaging (MRI) uses magnetic forces to image body structures. The presence of metals on the patient's body will interfere with the imaging process and leads to erroneous test results. The nurse instructs the patient to remove any metal items and clothing, like watches and credit cards. A protective cap is not necessary, as it does not interfere with the imaging process. An MRI is not affected by the presence of water or food in the stomach; the consumption of water is therefore not essential before an MRI. An MRI is not a painful technique, so analgesics are not required.

The nurse understands that generalized tonic-clonic seizures are the most common type of generalized seizure and include various phases. Arrange the phases of generalized tonic-clonic seizures in the correct order.

1. The patient loses consciousness. 2. The patient falls to the ground. 3. The body stiffens for 10 to 20 seconds. 4. The extremities jerk for 30 to 40 seconds. 5. The patient feels tired and sleepy. During a generalized tonic-clonic seizure, the patient loses consciousness and falls to the ground. This is followed by stiffening of the body for 10 to 20 seconds. There is a subsequent jerking of the extremities for another 30 to 40 seconds. The patient may then feel tired and sleep for few hours.

The nurse is teaching a group of student nurses about Parkinson disease. Which patients would be most likely to develop Parkinson disease? Select all that apply.

A 50-year-old male working in copper mines A 60-year-old male taking reglan (metoclopramide) A 50-year-old female taking compro (phenothiazine) The symptoms of Parkinson disease start at the age of 50, and their onset reaches a peak at 60 years. The incidence of Parkinson disease in men and women is in the ratio of 3:2. People who are exposed to chemicals, such as carbon monoxide and manganese, are at a higher risk for developing Parkinson disease, giving the 50-year-old male working in copper mines a higher risk of developing Parkinson disease. Drug-induced Parkinsonism is seen in patients who take selected antiemetics such as reglan (metoclopramide) and anti-psychotics such as compro (phenothiazine), putting the 60-year-old male and 50-year-old female taking Reglan (metoclopramide) and Compro (phenothiazine) at risk for Parkinson disease. African Americans are more likely to develop Parkinson disease than other ethnic groups. A 30-year-old Native American female is not likely to develop Parkinson disease. Considering the age and the sex of the person, a 30-year-old African American female is at lower risk of developing Parkinson disease.

A nurse is planning care for a patient with dysphagia secondary to a spinal cord injury. The nurse knows this patient is at risk for which serious complication?

Aspiration pneumonia. Aspiration pneumonia can result in a patient with difficulty swallowing. Inadequate nutrition is another consequence of dysphagia, but it is not as immediately life-threatening. Although a patient with difficulty swallowing may be at an increased risk for constipation as a result of dehydration, fecal impaction is not the most serious complication. Impaired skin integrity can result from inadequate nutrition, but this, too, is not the most serious complication.

A nurse is providing education to a patient in a yearly examination on ways to decrease the risk of neurovascular disease. Which characteristic, if exhibited by the patient, would indicate to the nurse that the patient is at an increased risk for neurovascular disease?

Blood pressure 142/94 mm Hg. Hypertension, high low-density lipoprotein (LDL) cholesterol, obesity, and sedentary lifestyle are risk factors for the development of neurovascular disease. This patient's risk factor is hypertension.

Which sensory function will be impaired in a patient who has had a cerebrovascular accident (CVA) affecting the hypothalamus?

Body temperature control. The hypothalamus is involved in controlling body temperature. In a patient who has sustained a cerebrovascular accident (CVA) and suffered hypothalamus damage, body temperature would continuously fluctuate. Muscle coordination is controlled by the cerebellum. Damage to the hypothalamus does not affect the patient's muscle coordination. The cerebrum - not the hypothalamus - controls thinking and reasoning. It is not affected by a CVA. Balance and equilibrium is controlled by cerebellum. Damage to the hypothalamus does not affect the patient's balance and equilibrium.

A nurse is caring for a patient receiving carbidopa-levodopa for Parkinson disease. Which instruction should the nurse give the patient to decrease the patient's risk of falling?

Change positions slowly. To reduce the risk of falling, the patient should change positions slowly because carbidopa-levodopa can cause orthostatic hypotension. The nurse should also instruct the patient to take the medication with food, closely monitor blood glucose levels, and remain upright after taking the medication. However, these instructions do not reduce the patient's risk of falling.

The nurse is performing a physical examination on a patient with Parkinson disease. What manifestations of Parkinson disease is the nurse likely to find? Select all that apply.

Drooling of saliva Decreased arm swing Shuffling, propulsive gait The patient may manifest drooling of saliva, shuffling, propulsive gait; and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia. Patchy blindness and nystagmus are not found in Parkinson disease.

The nurse is teaching a patient with myasthenia gravis about precautions to be taken to ensure safety and prevent any complications. What instructions should the nurse include in the patient teaching? Select all that apply.

Instruct the patient to wear medical-alert bracelets at all times. Instruct the patient to avoid crowds during flu and cold season. The patient should be instructed to wear a medical-alert bracelet that identifies the patient as having myasthenia gravis, which helps provide treatment when the patient becomes incapacitated. The patient does not have enough energy to cough effectively, resulting in pneumonia or airway obstruction. The patient should therefore be instructed to avoid crowds during flu and cold season to prevent respiratory infections. The patient should be instructed to eat while sitting up to prevent the risk of aspiration. The nurse should instruct the patient to take the medication early, before eating or engaging in any activities. The nurse should teach and encourage the patient to practice airway-protective techniques while swallowing. This prevents the possible risk of aspiration while swallowing.

When performing a physical assessment on a patient with amyotrophic lateral sclerosis, which manifestations is the nurse likely to find? Select all that apply.

Limb weakness Difficulty swallowing Difficulty articulating words Amyotrophic lateral sclerosis is a rare progressive neurologic disorder characterized by loss of motor neurons. The disease is characterized by limb weakness, difficulty in articulating words (dysarthria), and difficulty in swallowing (dysphagia). The symptoms are due to denervation of the muscles and lack of stimulation and use. Twisting movements of the face and involuntary movements of the body do not occur in amyotrophic lateral sclerosis.

A nurse is caring for a patient who is being evaluated for a neurologic disorder. The patient is not able to comprehend the written or spoken word. Which term would the nurse use to document this problem?

Receptive aphasia. Receptive aphasia is the inability to comprehend the written word or spoken word. Expressive aphasia is another name for motor aphasia; this is the inability to use symbols of speech. Global aphasia is the inability to understand the spoken word or to speak. Anomia is a form of aphasia characterized by the inability to name objects.

A nurse is assessing a patient using the Full Outline of UnResponsiveness (FOUR) score coma scale. Which categories will the nurse use to evaluate the patient's status? Select all that apply.

Respiration Eye response Motor response Brainstem reflexes The FOUR score coma scale uses respiration, eye response, motor response, and brainstem reflexes to measure the patient's level of consciousness and coma status. Verbal response is a part of the Glasgow Coma Scale.

A nurse is preparing a patient with suspected meningitis for a lumbar puncture to obtain cerebrospinal fluid for culture. How should the nurse position the patient for the procedure?

Right side in a fetal position. The patient should be positioned on the side in the fetal position to maximize the space between the lumbar vertebrae. Left lateral Sims, prone, and seated are not appropriate positions for a lumbar puncture.

A nurse is preparing to care for a patient with hemianopia. The nurse knows this results in which condition?

Seeing objects in only half of the visual field. Hemianopia is a condition in which the patient is unable to see half of the visual field. Diplopia is seeing two of each object. Seeing only objects that are close to the eyes is myopia. Presbyopia is seeing only objects that are far from the eyes.

A patient with multiple sclerosis is prescribed with a prophylactic dose of macrodantin (nitrofurantoin) and is asked to drink at least 2000 mL of fluids per day. What is the rationale for this prescription? Select all that apply.

To prevent urinary tract infections. To prevent difficulty in defecation. Patients with multiple sclerosis have frequent bladder and bowel problems due to neuronal degeneration. An adequate amount of fluids (at least 2000 mL/day) should be taken to prevent difficulty in defecation. Patients with multiple sclerosis are at a higher risk of developing urinary tract infections (UTI) and are therefore prescribed with a prophylactic dose of macrodantin (nitrofurantoin) to prevent the occurrence of UTIs. Patients who take medication for multiple sclerosis are at a higher risk for cardiac compromise. However, a prescription for macrodantin (nitrofurantoin) and the intake of fluids is unrelated to the prevention of cardiac problems. Patients with multiple sclerosis do not develop respiratory infections; therefore, the medication and fluid intake is completely unrelated to respiratory infection. Patients with multiple sclerosis do not develop liver disorders.

A patient with a head injury is assessed for the degree of consciousness impairment using the Glasgow Coma Scale. The patient opens his eyes, makes an incomprehensible speech, and gives an extension response to the pain experienced. What is the Glasgow score of the patient? Record your answer using a whole number.

7 Glasgow score = (Eye-opening response + Verbal response + Motor response). The patient scores 3 in eye-opening response, 2 each in verbal response and motor response. Therefore, the score of the patient is 7 (3+2+2). Patients with an objective score ranging between 3 and 8 are considered in coma.

A nurse is assisting the provider in testing the patient's cranial nerves. Which supplies would the provider need to test cranial nerve I?

Alcohol swabs. Cranial nerve I, the olfactory nerve, is tested by determining if the patient can identify common smells, such as alcohol. The flashlight, cotton fiber, and tongue blade would be used to test other cranial nerves, but not the olfactory nerve.

The nurse is teaching a patient about dietary habits that can trigger cluster headaches. Which food item should the patient avoid?

Alcohol. The patient with cluster headache should avoid alcohol, because it can trigger headache. Alcohol is the only dietary trigger for cluster headaches. Cheese, onions, and oranges may trigger migraine headache.

A patient comes to the clinic for a yearly examination. The nurse asks the patient her name, the year, and the location. The patient's responses are significant for the correct name, incorrect year, and correct location. How should the nurse document the patient's responses?

Alert and oriented × 2 (person and place). The patient is alert and oriented (A&O) to person and place. The person oriented to person, place, and time, or A&O × 3, would be able to answer with the correct name, year, and location. The person who is A&O × 0 would not be able to answer with the correct name, date, or year.

A patient is diagnosed with Bell's palsy. What prescriptions should the nurse expect from the primary health care provider (PHP)?

Apply warm moist heat on the cranial nerve. In a patient with Bell's palsy, the cranial facial nerves become inflamed. The immediate instruction from the PHP will be to place warm, moist heat on the affected nerve. This will maintain the muscle tone and prevent atrophy. Antibiotics are administered in cases of meningitis. Artificial oxygenation is provided, if the patient has a head injury or has difficulty breathing. IV immune globin (Sandoglobulin) is prescribed when the patient is diagnosed with polyneuritis (Guillain-Barre syndrome).

What is the earliest sign of increased intracranial pressure?

Change in level of consciousness (LOC) A change in LOC is the earliest sign of increased intracranial pressure. This change in LOC may include disorientation, restlessness, or lethargy. Widening pulse pressure occurs because of an increased systolic blood pressure (resulting from excitation of vasoconstrictor fibers from ischemia of the vasomotor center) coupled with a stable diastolic blood pressure. This occurs later in the process of increased intracranial pressure, when herniation is imminent. Ipsilateral pupil dilation will occur as a result of compression of cranial nerve III (oculomotor) when the lesion is in one hemisphere. This occurs later in the process of increased intracranial pressure, when herniation is imminent. An ataxic breathing pattern is an irregular and unpredictable breathing pattern with random, shallow, and deep breaths and occasional pauses. This will occur very late in the process of increased intracranial pressure.

A nurse is preparing to care for a patient with a Glasgow Coma Scale score of 7. The nurse knows this patient will require which level of assistance with activities of daily living?

Complete care, because the patient is in a coma. A Glasgow Coma Scale score of 3 to 8 is indicative of a coma. Therefore this patient with a score of 7 is in a coma and requires complete care. The patient is not in a semicomatose, stuporous, or mildly disoriented state.

A nurse is providing education to a 50-year-old woman on decreasing her risk of developing Alzheimer disease (AD). Which instruction would be most helpful for this patient?

Complete crossword and other puzzles daily. Studies have shown that the patient should be encouraged to engage in activities that require the processing of new information such as puzzles and learning a new language. Exercise and healthy diet are important to AD prevention, as well. The patient should consume foods high in beta carotene and antioxidants. A patient who is beginning to experience symptoms of AD should be instructed to keep a detailed calendar and write in a diary often.

A nurse is caring for an intubated and mechanically ventilated patient with an increased intracranial pressure (ICP). The patient's arterial blood gas results show a normal pH and carbon dioxide level. The nurse receives a prescription to increase the respiratory rate of the patient's ventilator. The nurse knows this change should have which change on the patient's ICP?

Decrease the ICP because of vasoconstriction caused by a decrease in carbon dioxide. Increasing the respiratory rate causes the patient to blow off carbon dioxide, which leads to vasoconstriction of the cerebral blood vessels, which will lead to a decrease in intracranial pressure. Increased respiration does not lead to vasodilation as a result of an increase in pH or a decrease in carbon dioxide. This is an appropriate respiratory change and does not need to be verified with the provider.

A nurse caring for a patient with a risk for increased intracranial pressure (ICP) knows to be vigilant for which early sign of increased ICP?

Decreased level of consciousness. Decreased level of consciousness is the first sign of increasing ICP. Projectile vomiting, widened pulse pressure, and unilateral unequal and unresponsive pupil are all late signs of increased ICP.

The nurse is caring for a patient with multiple sclerosis. What information should the nurse include when teaching the patient about advantages of exercise for multiple sclerosis? Select all that apply.

Decreases spasticity Increases coordination Retrains unaffected muscles to substitute for impaired ones Patients with multiple sclerosis not experiencing an exacerbation should be encouraged to exercise. Regular exercise can help to decrease spasticity, increase coordination, and retrain unaffected muscles to substitute for the impaired ones. The exercise does not help in regaining bladder control or delaying the demyelination process.

A patient with long-term, poorly controlled type 2 diabetes mellitus comes to the clinic complaining of tingling and burning in the legs and numbness in the toes. The nurse anticipates which diagnosis?

Diabetic neuropathy. Poorly controlled diabetes can lead to damage of the peripheral nervous system, which can cause a burning, tingling, and numbness called diabetic neuropathy. Phantom limb pain occurs after an amputation. Postherpetic neuralgia is pain after the resolution of a herpes infection. Trigeminal neuralgia affects the trigeminal nerve, which is a cranial nerve.

A nurse is caring for a patient who has recently developed symptoms of increased intracranial pressure (ICP) including decreased level of consciousness. The nurse anticipates administering which medication to emergently decrease intracranial pressure?

Mannitol. Mannitol is an osmotic diuretic that pulls water from the brain tissue to decrease ICP. Versed and Dilantin are commonly used in the treatment of increased ICP, but these are used to sedate and control seizures, respectively, not decrease ICP. Tagamet is prescribed if dexamethasone (Decadron) is prescribed.

A nurse is caring for a patient with increased intracranial pressure (ICP) who is intubated and mechanically ventilated. The nurse knows endotracheal suctioning should be performed how often?

When the patient's oxygen level drops as a result of respiratory secretions. Suctioning increases the patient's ICP, so it should be performed only when necessary. The patient's position should not be changed. Suctioning should be performed only hourly or when vital signs are obtained if the patient's respiratory status would be compromised by not suctioning.

A patient comes to the clinic for a yearly examination. The nurse notes that the patient is able to speak but must point to areas that are causing pain instead of simply naming the body part. The nurse suspects which type of aphasia?

Anomic aphasia. Anomic aphasia is the inability to name objects. Motor aphasia is the inability to speak or write. Global aphasia is the inability to understand the spoken word or to speak. Receptive aphasia is the inability to understand the spoken or written word.

A nurse is caring for a patient with myasthenia gravis. The nurse knows weakness of which muscles is the most dangerous complication of myasthenia gravis?

Diaphragm. Although the patient may experience weakness of the diaphragm, vocal cord, anal and bladder sphincters, the most dangerous is the diaphragm, because the diaphragm is required for spontaneous respiration. Patients with weakness of the diaphragm may need to be mechanically ventilated to sustain life.

A nurse is contributing to the admission assessment of a patient who is noted to be unable to follow simple commands, replies slowly and after much thought, is not paying attention to commands, and responds without much character. The nurse knows to document which level of consciousness for this patient?

Disorientation. This patient is demonstrating a disoriented level of consciousness. This patient is clearly not alert, but is also not in a stupor or semicomatose.

What neurotransmitter primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles?

Dopamine. The neurotransmitter that primarily affects motor function and is involved in gross subconscious movements of the skeletal muscles is dopamine. Dopamine also plays a role in emotional responses. In Parkinson disease, there is a deficiency of dopamine and the patient develops tremors or involuntary trembling movements. Acetylcholine plays a role in nerve impulse transmission; it spills into the synapse area and speeds the transmission of the impulse. Norepinephrine has an impact on maintaining arousal, dreaming, and regulation of mood. Serotonin induces sleep, affects sensory perception, controls temperature, and has a role in the control of mood.

A patient has scotoma, dysarthria, nystagmus, and bowel and bladder problems. Upon reviewing the diagnostic test results, the nurse suspects that the patient has multiple sclerosis. What results would lead to this conclusion? Select all that apply.

Elevated gamma globulin present in the cerebrospinal fluid (CSF). 3-4 mm sclerotic brain plaques on a magnetic resonance (MRI) scan. Multiple sclerosis does not have any specific diagnostic tests. However, it can be diagnosed from cerebrospinal fluid (CSF) analysis and an MRI scan. The CSF of a multiple sclerosis patient shows elevated gamma globulin, lymphocytes, and monocytes. An MRI scan of the brain in a multiple sclerosis patient shows multiple sclerotic plaques of 3-4 mm diameter. A CT scan detects brain tumors and thrombi in the form of areas of increased density. Decreased glucose levels in the CSF may indicate a fungal, bacterial or viral infection, such as meningitis. CSF containing elevated spinal fluid protein may indicate the presence of degenerative diseases or a brain tumor. The presence of blood in the CSF may indicate a hemorrhage in the brain or the spinal cord.

A nurse is caring for a patient with multiple sclerosis. What appropriate nursing intervention should be implemented?

Encouraging a well-balanced diet high in fiber and adequate fluids. Appropriate nursing care for a patient with multiple sclerosis includes encouraging a well-balanced diet high in fiber and adequate fluids. Supplemental vitamins are usually encouraged. Obesity will make it more difficult for the patient to meet daily needs and maintain mobility; the patient who is obese will probably be referred to a dietitian and placed on a calorie-restricted diet. Fluid restriction is not an appropriate nursing intervention; the patient with multiple sclerosis is usually encouraged to consume 2 L of fluid per day or more. Appropriate nursing care for a patient with multiple sclerosis includes teaching the patient to avoid hot baths, because they can increase weakness. Avoidance of hot weather to the extent possible can also help reduce fatigue in the patient with multiple sclerosis. Appropriate nursing care for a patient with multiple sclerosis includes teaching the patient to exercise regularly, but not to the point of fatigue. Daily rest periods may be helpful. During an acute exacerbation, patients are usually kept as quiet as possible; this includes bed rest.

A male patient has been recently diagnosed with Parkinson disease. His wife asks the nurse numerous questions about the disease. What information is correct in addressing this wife's questions?

Parkinson disease is a syndrome of bradykinesia, rigidity, tremor, and impaired postural reflexes. Parkinson disease is a syndrome of slowing down in the initiation of movement (bradykinesia), increased muscle tone (rigidity), tremor, and impaired postural reflexes. Parkinson disease is more common in men than in women by a ratio of 3:2. The tremor from Parkinson disease is more prominent at rest and decreases with movement of the affected body part. There is normally a balance between the neurotransmitters acetylcholine and dopamine in the basal ganglia. Symptoms of Parkinson disease appear when there is either a decrease in dopamine or an increase in acetylcholine levels.

A nurse is contributing to the admission assessment of a patient who reports taking carbidopa-levodopa, selegiline (Eldepryl), and pramipexole (Mirapex). Based on these prescription medications, the nurse knows the patient has which disorder?

Parkinson disease. Carbidopa-levodopa, Eldepryl, and Mirapex are used to treat Parkinson disease, not epilepsy, multiple sclerosis, or diabetic neuropathy.

A nurse is supervising the care of a patient with multiple sclerosis (MS) by an unlicensed assistive personnel (UAP). Which action by the UAP would prompt the nurse to intervene immediately?

Preparing to place the patient in a bathtub with hot water. Hot water and hot ambient temperatures can lead to muscle weakness. The patient should be encouraged to perform light exercise, rest frequently, and remain in a cool environment.

The nurse prepares a patient for lumbar puncture. What is the most preferable positioning of the patient?

Side-lying with head and knee flexed at an angle. Lumbar puncture is a diagnostic procedure performed in patients who may have a neurologic problem. During the procedure, the patient should be placed in the side-lying position with the head bent down to the chest and their knees bent up to the abdomen. This position is marked by a flexed angle between the knee and head. The position allows for the maximal lumbar flexion and separation of the inter-spinous spaces. Side-lying, with a pillow placed under the hip, will not provide maximum lumbar flexion. The prone position is suggested for patients with disturbed muscle tone. The prone position, with a pillow placed under the abdomen, will not increase lumbar flexion.

A patient with a history of cluster headaches is planning to travel overseas by air. What advice should the nurse give to this patient to decrease the likelihood of such attacks during air travel?

Take ergotamine before the flight takes off. Cluster headache attacks may occur at high altitudes with low oxygen levels during air travel. Ergotamine, taken before the plane takes off, may decrease the likelihood of these attacks. Patients with cluster headaches can travel by air with precautions to avoid the headaches. Consumption of food items including chocolate, cheese, or tomatoes is not related to cluster headaches, but it may trigger migraine headaches. Massaging and applying moist hot packs to the neck and head can help a patient with tension-type headaches, but it may not help relieve cluster headaches.

What should the primary health care provider expect to find when reviewing the diagnostic test results of the patient with Parkinson disease? Select all that apply.

The computed tomography (CT) scan of the brain shows cerebral atrophy. There is decreased motility seen in the patient's upper gastrointestinal tract. There is positive response given to the low-dose Sinemet (carbidopa-levodopa). There is no specific diagnostic test to confirm Parkinson disease. The presence of cerebral atrophy in the CT scan may indicate Parkinsonism. A patient with Parkinson disease shows decreased motility in the upper gastrointestinal tract. The ultimate confirmation test to diagnose Parkinson disease is to treat the patient with a low-dose of Sinemet (carbidopa-levodopa). A positive response by the patient to this test confirms the presence of Parkinson's disease. A patient with increased intracranial pressure shows structural herniation of brain in the CT scan. The presence of lesions in the MRI scan may indicate the presence of multiple sclerosis or epilepsy.

When taking the history of a patient with a migraine headache, what features of a migraine headache is the patient likely to report? Select all that apply.

The headache is usually unilateral. The headache is preceded by an aura. The headache is usually triggered by foods, such as chocolate. Migraine headaches are usually unilateral and are usually preceded by an aura, which can be a visual, sensory, or motor phenomenon. The headache can be triggered by certain foods, including chocolate, cheese, tomatoes, onions, and oranges. Migraine headaches may last from 4 hours to 72 hours. The nature of the headache is not sharp and stabbing but rather steady and throbbing.