ch 64- Neurologic Infections, Autoimmune Disorders, and Neuropathies

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first? Apply a cooling blanket. Ensure the family receives prophylaxis antibiotic treatment. Initiate isolation precautions. Administer prescribed antibiotics.

Initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

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? Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 72 hours after exposure Within 48 hours after exposure Within 24 hours after exposure

Within 24 hours after exposure

Bell palsy is a disorder of which cranial nerve?

Facial (VII)

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply. Deep tissue injury Stage I Stage II Stage III Stage IV

Stage III Stage IV

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "The paralysis caused by this disease is temporary." "You'll first regain use of your legs and then your arms." "You'll be permanently paralyzed; however, you won't have any sensory loss." "It must be hard to accept the permanency of your paralysis."

"The paralysis caused by this disease is temporary."

The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "It's too early to give a prognosis." "Don't worry; your child will be fine."

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following? Inability to swallow Bulbar weakness 20/20 vision Blindness

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

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements? The thymus gland is removed. Antibodies are removed from the plasma. Mestinon therapy is initiated. Immune globulin is given intravenously.

Antibodies are removed from the plasma.

Which drug should be available to counteract the effect of edrophonium chloride? Azathioprine Pyridostigmine bromide Prednisone Atropine

Atropine

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Diplopia and ptosis Patchy blindness Numbness Loss of proprioception

Diplopia and ptosis

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test? Immunoglobulin G (Iveegam EN) Cyclosporine (Sandimmune) Edrophonium (Tensilon) Azathioprine (Imuran)

Edrophonium (Tensilon)

A rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest? Avoid seeking help from others. Stop any activity once fatigue occurs. Group any heavy work to be done at the same time. Emphasize areas of strengths.

Emphasize areas of strengths.

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? Fatigue and depression Ptosis and diplopia Hyporeflexia and weakness of the lower extremities Facial distortion and pain

Facial distortion and pain

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.) Have a fluid intake between 2 and 4 L/day. Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Take a retention enema daily. Take a laxative daily.

Have a fluid intake between 2 and 4 L/day. Have an adequate intake of fiber containing foods. Set a daily defecation time that is within 15 minutes of the same time every day.

Which is the most common cause of acute encephalitis in the United States? Herpes simplex virus West Nile virus St. Louis virus Western equine virus

Herpes simplex virus

The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority? Provide instruction on blood-thinning medication. Assess client for ability to ambulate independently. Praise client when using adaptive equipment. Include client in planning of care and setting of goals.

Include client in planning of care and setting of goals.

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? Assess for facial weakness. Assess visual acuity. Ensure that client takes nothing by mouth. Initiate seizure precautions.

Initiate seizure precautions.

A client is at risk for pressure ulcers. Which of the following would be most appropriate to include in the plan of care? Massaging any reddened areas of the skin Placing the client in a semi-reclining position Lubricating the skin with a non-irritating lotion Having the client shift his or her weight every hour

Lubricating the skin with a non-irritating lotion

The diagnosis of multiple sclerosis is based on which test? Neuropsychological testing Magnetic resonance imaging (MRI) Cerebrospinal fluid (CSF) electrophoresis Evoked potential studies

Magnetic resonance imaging (MRI)

Which of the following is considered a central nervous system (CNS) disorder? Multiple sclerosis Bell's palsy Myasthenia gravis Guillain-Barré

Multiple sclerosis

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? Neck flexion produces flexion of knees and hips Numbness and tingling in the lower extremities Inability to stand with eyes closed and arms extended without swaying Pain upon ankle dorsiflexion of the foot

Neck flexion produces flexion of knees and hips

The most common cause of cholinergic crisis includes which of the following? Infection Undermedication Compliance with medication Overmedication

Overmedication Overmedication

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation? Fatigue primarily results from physical demands. Priority setting is helpful in dealing with the impact of the disability. Most care tasks required after discharge focus on the physical care. A loss of sexual functioning correlates with a loss of sexual feeling.

Priority setting is helpful in dealing with the impact of the disability.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? Water Protein Vitamin C Zinc sulfate

Protein

Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? Providing palliative care Initiating isolation procedures Administering amphotericin B Preparing for organ donation

Providing palliative care

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power? Active exercises Passive exercises Isometric exercises Resistive exercises

Resistive exercises

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? Serum albumin Sedimentation rate Serum glucose Prothrombin time

Serum albumin Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g per dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Serum glucose is used to assess for diabetes. Prothrombin time is used to assess clotting time and monitor therapeutic levels of anticoagulation medications. Sedimentation rate is used to detect inflammation in the body.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? Carries message to the next nerve cell Speeds nerve impulse transmission Represents building block of nervous system Acts as chemical messenger

Speeds nerve impulse transmission

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? Stage I pressure ulcer Stage III pressure ulcer Stage II pressure ulcer Stage IV pressure ulcer

Stage II pressure ulcer

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage? Stage IV Stage III Stage II Stage I

Stage III

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Tensilon test Serum studies Computed tomography (CT) scan Electromyogram (EMG)

Tensilon test

The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news? The client will progress sequentially through five stages of the grief process. The client will require psychotherapy to process his grief. The client will go through the stages of grief over the next week to 10 days. The client will experience grief in an individualized manner.

The client will experience grief in an individualized manner.

The nurse is providing care for a 90-year-old client whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? The soles of the client's feet The client's heels The client's knees The client's elbows

The client's heels

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? The physical therapist The patient The nurse The physician

The patient

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply. Cooking Toileting Eating Bathing Cleaning

Toileting Eating Bathing

A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound healing? Vitamin D Calcium Vitamin E Vitamin C

Vitamin C

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: Kernig's sign. a positive edrophonium (Tensilon) test. Brudzinski's sign. a positive sweat chloride test.

a positive edrophonium (Tensilon) test.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: advance both crutches. advance both legs. advance the affected leg. advance the unaffected leg.

advance both crutches.

The primary arthropod vector in North America that transmits encephalitis is the horse. tick. mosquito. flea.

mosquito.

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply. overall risk of developing pressure ulcers potential areas of pressure ulcer development presence of pressure ulcers on the client indwelling catheter output family history of pressure ulcers

presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development

The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's: level of joint pain. muscle size. deep tendon reflexes (DTRs). range of motion.

range of motion.

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: avoid naps during the day. take a hot bath. rest in an air-conditioned room. increase the dose of muscle relaxants.

rest in an air-conditioned room.

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown? Practice meticulous hygiene measures. Place an indwelling catheter in the patient. Apply powder. Administer vitamin B12 to the patient.

Practice meticulous hygiene measures. Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Placing an indwelling catheter and administering vitamin B12 would not be effective measures in preventing continuous moisture.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: functional incontinence. reflex incontinence. total incontinence. stress incontinence.

stress incontinence.