Chapter 37, Caring for Clients With Central and Periphera.rtf

A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam (Valium) 0.25 mg/kg. How many milligrams will be given to this client? _______________________________ mg

Ans: 15 mg Feedback: Step 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A) An absence seizure B) A myoclonic seizure C) A partial seizure D) A tonic-clonic seizure

Ans: A Feedback: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness

The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? A) "Antibodies that triggered the autoimmune response are removed from your blood." B) "The blood removal allows for replacement of cleaner blood from a healthy person." C) "Blood transfusions are the gold standard for the treatment of this syndrome." D) "Plasma replacement dilutes the organisms that are causing the symptoms."

Ans: A Feedback: Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood transfusion) has emerged as a major treatment intervention.

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A) Damage to the nerves that facilitate vision and hearing B) Damage to the vagal nerve C) Damage to the olfactory nerve D) Damage to the facial nerve

Ans: A Feedback: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.

You are caring for a client with an inoperable brain tumor. What is a major threat to this client? A) Increased ICP B) Decreased ICP C) Hypervolemia D) Hypovolemia

Ans: A Feedback: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. I.

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose? A) Slows the progression of the disease B) Replaces dopamine C) Relieves symptoms of dyskinesia D) Prevents side effects from Sinemet

Ans: A Feedback: Selegiline (Eldepryl) increases dopaminergic activity and slows the progression of the disease. Carbidopa-levodopa (Sinemet) is a dopamine replacement drug. Anticholinergic drugs (such as Cogentin) are used to reduce the symptoms of dyskinesia and other side effects.

Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A) Blood pressure 100/60 mm Hg B) Lethargy C) Nausea D) Periorbital edema

Ans: B Feedback: Decreasing level of consciousness is one of the earliest signs of increased ICP.

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? A) Assess client's reaction to new medication schedule. B) Administer medications at exact intervals ordered. C) Document medication given and dose. D) Give client plenty of fluids with medications.

Ans: B Feedback: He or she must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.

A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse? A) "It is not uncommon for seizure activity to occur after head trauma." B) "Only a portion of your brain has been irritated." C) "Generalized seizures are much worse and involve the entire brain." D) "Electrical impulses become confused and chaotic resulting in a seizure."

Ans: A Feedback: The client wants a simple explanation to help alleviate fears and concerns. Explaining that seizures are common (or even normal)

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A) Elevate the head of the bed. B) Complete a head-to-toe assessment. C) Administer morning dose of anticonvulsant. D) Administer Percocet as ordered.

Ans: A Feedback: The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? A) Take small meals of nutrient and calorie-dense food. B) Increase the intake of calcium and proteins. C) Include additional servings of fruits and raw vegetables. D) Include fish, liver, and chicken in diet.

Ans: A Feedback: To help a client with trigeminal neuralgia who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating.

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. A) Cloudy cerebral spinal fluid B) Pain and stiffness of the extremities C) Purpura of hands and feet D) Low white blood cell (WBC) count E) Low red blood cell (RBC) count F) Low antidiuretic hormone (ADH) levels

Ans: A, C Feedback: The CSF will be cloudy if bacterial meningitis is the causative agent.

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

Ans: B Feedback: An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? A) Avoid stimuli that trigger pain. B) Use ophthalmic lubricant and protect the eye. C) Encourage semiannual dental exams. D) Complete the course of antibiotics as prescribed.

Ans: B Feedback: The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? A) "Hospice care uses a team approach and provides complete care." B) "Clients and families are the focus of hospice care." C) "The physician coordinates all the care delivered." D) "All hospice clients die at home."

Ans: B Feedback: The most important component of hospice care is the focus that is placed on the care of the client as well as the family.

24. The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? A) Observe for jaundice. B) Assess for euphoria. C) Monitor vital sign fluctuation. D) Monitor for elevation of glucose levels.

Ans: C Feedback: Adverse effects of dopamine replacement drugs include cardiac dysrhythmias, hypotension, muscle cramps, and GI distress.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A) Seizure began at 1300 hours. B) The client cried out before the seizure began. C) Seizure was 1 minute in duration including tonic-clonic activity. D) Sleeping quietly after the seizure

Ans: C Feedback: Describing the length and the progression of the seizure is a priority nursing responsibility.

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? A) Assessing skull dressing for excess drainage B) Time, distance, and shielding against radiation C) Assess neurological findings. D) Maintain airway via artificial ventilation.

Ans: C Feedback: Gamma-knife radiosurgery is a non-invasive alternative for treating tumors within the brain. The nurse would be responsible for completing a neurological assessment on the client and providing comfort measures as needed.

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? A) "I will have progressive muscle weakness." B) "I will lose strength in my arms." C) "My children are at greater risk to develop this disease." D) "I need to remain active for as long as possible."

Ans: C Feedback: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses.

A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client? A) Impaired Home Maintenance B) Altered Nutrition C) Hopelessness D) Disturbed Sleep Pattern

Ans: C Feedback: Huntington's disease is an inherited disease that has progressive physical, emotional, and mental involvement.

A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? A) Blood pressure is rising. B) Level of consciousness is improving. C) Urine output is increased. D) Hyperpyrexia is resolving.

Ans: C Feedback: Mannitol is a hypertonic solution that helps to pull fluid from the cells into the vascular system where the kidneys can eliminate as urine.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? A) Change in level of consciousness B) Vomiting C) Vector bites D) Seizures

Ans: C Feedback: Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? A) Loss of bowel and bladder control B) Choreiform movements C) Suicidal ideations D) Emotional apathy

Ans: C Feedback: Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? A) Optimizing nutrition B) Managing muscle weakness C) Explaining hospice care and services D) Offering family support groups

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

A client you are caring for experiences a seizure. What would be a priority nursing action? A) Restrain the client during the seizure. B) Insert a tongue blade between the teeth. C) Protect the client from injury. D) Suction the mouth during the convulsion.

Ans: C Feedback: The nursing action for a client experiencing a seizure should be to protect the client from being injured.

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A) Insert an airway or bite block. B) Manually restrain the extremities. C) Turn client to side-lying position. D) Monitor vital signs.

Ans: C Feedback: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth.

A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? A) Sleep pattern B) Mood and affect C) Appetite D) Muscle spasms

Ans: D Feedback: Baclofen (Lioresal) is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A) Epilepsy B) Trigeminal neuralgia C) Hypostatic pneumonia D) Brain tumor

Ans: D Feedback: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult.

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? A) Shortness of breath B) Sensitivity to bright light C) Muscle spasms D) Drooping eyelids

Ans: D Feedback: Ptosis is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses.

23. Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? A) Involvement with diversion activities B) Enhancement of the immune system C) Establishing balanced nutrition D) Maintaining a safe environment

Ans: D Feedback: The primary focus in caring for Parkinson's disease is on maintaining a safe environment.

13. A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A) Dextrose 5% in water (D5W) B) Half-normal saline (0.45% NSS) C) One-third normal saline (0.33% NSS) D) Mannitol (Osmitrol)

Ans: D Feedback: With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. A) Stiff neck B) Generalized pain C) Glasgow Coma Scale of 15 D) Elevated systolic blood pressure E) Brisk pupil response F) Wide pulse pressure

Ans: D, F Feedback: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP

A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? A) Provide information of the progression of the disease. B) Encourage client to verbalize fears. C) Explain that inherited risk is 50%. D) Offer genetic testing.

Ans: B Feedback: Huntington's disease is a hereditary disorder of the CNS that is progressive and has no cure. Being able to verbalize fears and concerns that are real can be therapeutic for the client.

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside? A) Nebulizer and thermometer B) Intubation tray and suction apparatus C) Blood pressure apparatus D) Incentive spirometer

Ans: B Feedback: Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary.