Ch. 69: Mgmt of Pts w/ Neurologic Infections, Autoimmune Disorders, & Neuropathies

Myasthenia gravis occurs when antibodies attack which receptor sites? Gamma-aminobutyric acid Serotonin Dopamine Acetylcholine

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

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

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

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario? Dantrium Lioresal Zanaflex Valium

Correct response: Lioresal Explanation: Baclofen (Lioresal), a gamma-aminobutyric acid (GABA) agonist, is the medication of choice for treating spasticity. It can be administered orally or by intrathecal injection.

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

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

Which of the following is the first-line therapy for myasthenia gravis (MG)? Pyridostigmine bromide (Mestinon) Lioresal (Baclofen) Deltasone (Prednisone) Azathioprine (Imuran)

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

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. Increased white blood cells Decreased protein Increased glucose Decreased glucose Increased protein

Correct response: Decreased glucose Increased protein Increased white blood cells Explanation: CSF studies demonstrate decreased glucose, increased protein levels, and increased white blood cells.

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

Correct response: Herpes simplex virus Explanation: Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? "I was brushing my teeth." "I was sitting at home watching television." "I was putting my shoes on." "I was taking a bath."

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

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

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

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Muscle weakness and hyporeflexia of the lower extremities Hyporeflexia and skin rash Fever and cough Ptosis and muscle weakness of upper extremities

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

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

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

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at preventing muscular atrophy. controlling seizures and increased intracranial pressure. preventing renal insufficiency. maintaining hemodynamic stability and adequate cardiac output.

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

Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine Acetylcholine GABA

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

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe? Hyporeflexia in the lower extremities Numbness and vomiting Headache and nuchal rigidity Ptosis and diplopia

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

Which is the most common cause of acute encephalitis in the United States? Lyme Disease Human immunodeficiency virus (HIV) Western equine bacteria Herpes simplex virus (HSV)

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

Bell palsy is a disorder of which cranial nerve? Facial (VII) Vagus (X) Vestibulocochlear (VIII) Trigeminal (V)

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

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis? Preventing renal insufficiency Maintaining hemodynamic stability and adequate cardiac output Controlling seizures and increased intracranial pressure Preventing muscular atrophy

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

Which is the primary vector of arthropod-borne viral encephalitis in North America? Mosquitoes Birds Ticks Spiders

Correct response: Mosquitoes Explanation: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.

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

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

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Respiratory Gastrointestinal Urinary Skin

Correct response: Respiratory Explanation: Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.

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

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

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? destabilizing client's condition preventing further neurologic damage reporting changes to the physician assessing vital signs frequently

Correct response: preventing further neurologic damage Explanation: The focus of management during the acute phase is to stabilize the client and prevent further neurologic damage.

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? Primary progressive Benign Disabling Relapsing-remitting (RR)

Correct response: Relapsing-remitting (RR) Explanation: 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.

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain? Multiple sclerosis Parkinson disease Huntington disease Creutzfeldt-Jakob disease

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

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? Edrophonium (Tensilon) Pyridostigmine (Mestinon) Ambenonium (Mytelase) Carbachol (Carboptic)

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

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate? Bedrest at home for 72 hours No treatment unless the roommate begins to show symptoms Admission to the nearest hospital for observation Treatment with antimicrobial prophylaxis as soon as possible

Correct response: Treatment with antimicrobial prophylaxis as soon as possible Explanation: People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 72 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 24 hours after exposure Within 48 hours after exposure

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

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: take a hot bath. avoid naps during the day. rest in an air-conditioned room. increase the dose of muscle relaxants.

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

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? "I will take hot tub baths to decrease spasms." "The exercises should be completed quickly to reduce fatigue." "I should participate in non-weight-bearing exercises." "I will stretch daily as directed by the physical therapist."

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

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems? Frontal lobe abscess Cerebellar abscess Temporal lobe abscess Wernicke's abscess

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

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? Call the rapid response team because the patient is preparing to arrest. Place the patient in the supine position. Administer atropine to control the side effects of edrophonium. Administer diphenhydramine (Benadryl) for the allergic reaction.

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

Which nursing intervention is the priority for a client in myasthenic crisis? Preparing for plasmapheresis Administering intravenous immunoglobin (IVIG) per orders Ensuring adequate nutritional support Assessing respiratory effort

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

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? After administration of the medication, there will be no change in the status of the ptosis or facial weakness. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

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

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse? Accept the patient's behavior and do not take it personally. Discontinue the bath and resume it later. Request that the patient be cared for by another nurse. Explain that the client is getting good care.

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

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? Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Fatigue and depression Facial distortion and pain

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

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? Medications must be taken on time. There is no conflict with the disorder and dental work. Medications are best taken while the client is in a reclining position. Medications can be taken whenever convenient.

Correct response: Medications must be taken on time. Explanation: If medications are not taken on time, exacerbations may occur, making it impossible for the client to take the medication orally. Medications must always be taken with the client upright to avoid aspiration. Procaine (Novocain) should be avoided and the client's dentist must be informed.

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

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

Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident? Use of adaptive equipment Prevention of joint contractures Creating a positive environment Promoting ability to critically think

Correct response: Prevention of joint contractures Explanation: First addressed in the acute phase, however, impacting the rehabilitative process is the prevention of joint contractures. The nursing care provided at an early period can prevent further complications in the rehabilitative phase. Promoting the ability to critically think is not a priority in the acute phase. Creating a positive environment is helpful in motivating the client. Using adaptive equipment is not a focus in the acute phase of the disease process.

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

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

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? "You'll first regain use of your legs and then your arms." "The paralysis caused by this disease is temporary." "It must be hard to accept the permanency of your paralysis." "You'll be permanently paralyzed; however, you won't have any sensory loss."

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

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? "Don't worry; your child will be fine." "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." "It's too early to give a prognosis." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly."

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

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? Turn out the lights in the room. Instill artificial tears. Encourage the client to close his eyes. Alternatively patch one eye every 2 hours.

Correct response: Alternatively patch one eye every 2 hours. Explanation: 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.

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

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

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Renal Hepatic

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

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? 1 hour after the antibiotic has infused and daily for 7 days 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days 2 hours prior to the administration of antibiotics for 7 days It can be administered every 6 hours for 10 days.

Correct response: 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Explanation: Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding (Bader & Littlejohns, 2010).

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe? Hyporeflexia and weakness of the lower extremities Facial pain in the areas of the fifth cranial nerve Ptosis and diplopia Fatigue and depression

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

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Decreased pulse rate, abdominal breathing Increased pulse rate, respirations of 16 breaths/minute Decreased pulse rate, respirations of 20 breaths/minute Increased pulse rate, adventitious breath sounds

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

A client is suspected to have bacterial meningitis. What is the priority nursing intervention? Encourage oral fluid intake. Administer prescribed antibiotics. Assess the CSF fluid laboratory test results. Prepare the client for a CT scan.

Correct response: Administer prescribed antibiotics. Explanation: A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? Approximately 60% to 75% of clients recover completely. No one with Guillain-Barre syndrome recovers completely. Usually 100% of clients recover completely. Only a very small percentage (5% to 8%) of clients recover completely.

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

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) Azathioprine (Imuran) Cyclosporine (Sandimmune) Edrophonium (Tensilon)

Correct response: Edrophonium (Tensilon) Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? Change body position every 2 hours. Use a footboard and trochanter rolls. Help the client perform range-of-motion (ROM) exercises every 8 hours. Use pressure-relieving devices when the client is in bed or in a wheelchair.

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

A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take? Assess the patient's sensitivity to light. Help the patient flex his neck and observe for flexion of the hips and knees. Flex the patient's thigh on his abdomen and assess the extension of the leg. Support the patient's neck through normal range of motion and evaluate stiffness.

Correct response: Help the patient flex his neck and observe for flexion of the hips and knees. Explanation: A positive Brudzinski sign: When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.

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? Ensure the family receives prophylaxis antibiotic treatment. Initiate isolation precautions. Apply a cooling blanket. Administer prescribed antibiotics.

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

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? Parkinson disease Multiple sclerosis Creutzfeldt-Jakob disease Huntington disease

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

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Parkinson disease Multiple sclerosis Creutzfeldt-Jakob disease Huntington disease

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

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? Endocrine system Respiratory system Neurovascular system Cardiovascular system

Correct response: Neurovascular system Explanation: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Tell the patient to smile every 4 hours.

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

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms are primarily associated with infection with Coccidioides immitis and Aspergillus. indicate renal toxicity and a worsening condition. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures.

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