Chapter 46: Nursing Management: Patients with Neurologic Disorders

A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A) Applying a protective eye shield at night B) Chewing on the affected side to prevent unilateral neglect C) Avoiding the use of analgesics whenever possible D) Avoiding brushing the teeth

Ans: A Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient should be encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient? A) MS is a progressive demyelinating disease of the nervous system. B) MS usually occurs more frequently in men. C) MS typically has an acute onset. D) MS is sometimes caused by a bacterial infection.

Ans: A Feedback: MS 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. The cause of MS is not known, and the disease affects twice as many women as men.

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

Ans: B Feedback: Clinical manifestations of bacterial meningitis include a positive Brudzinskis sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinskis sign. Positive Homans sign (pain upon dorsiflexion of the foot) and negative Rombergs sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A) Arrange for the patient to receive a low residue diet. B) Position the patient upright during feeding. C) Suction the patient following each meal. D) Withhold liquids until the patient has finished eating.

Ans: B Feedback: Correct, upright positioning is necessary to prevent aspiration in the patient with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration.

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patients complaints of headache? A) Initiating a patient-controlled analgesia (PCA) of morphine sulfate B) Administering hydromorphone (Dilaudid) IV as needed C) Dimming the lights and reducing stimulation D) Distracting the patient with activity

Ans: C Feedback: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms, therefore, they are used cautiously. Non-opioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the patients pain.

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient? A) Suctioning secretions B) Facilitating ABG analysis C) Providing ventilatory assistance D) Administering tube feedings

Ans: C Feedback: Providing ventilatory assistance takes precedence in the immediate management of the patient with myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are not the priority for this patient. ABG analysis will be done, but this is not the priority.

20. A community health nurse is conducting a home visit to a male patient who has Parkinson's disease (PD). The nurse has been working closely with the patient and his wife to prevent the many possible complications of the disease. What recommendation should the nurse make to improve nutrition? A) Have the patient drink nutritional supplements in lieu of solid food B) Replace complex carbohydrates with simple carbohydrates C) Allot a large amount of time for each meal of the day D) Have the patient drink fluids before and after meals but not during meals

C) Allot a large amount of time for each meal of the day - Eating becomes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing. An electric warming tray keeps food hot and allows the patient to rest during the prolonged time that it may take to eat.

A female patient has presented to the emergency department (ED) with complaints of a high fever and severe headache. The patient states that acetaminophen has had no appreciable effect on either symptom. The triage nurse recognizes the need to perform a rapid assessment for possible meningitis and should ask which of the following questions: - "Have you done any travelling in the last few weeks?" - "Have you had a nosebleed since this problem started?" - "Have you noticed any tremors in your hands or arms?" - "Are you having stiffness or pain in your neck-?

Correct response: "Are you having stiffness or pain in your neck?" Explanation: Nuchal rigidity is an early sign of meningitis that is seen in 30% to 70% of patients. Nosebleed and tremors are not characteristic of meningitis, and the disease is not commonly preceded by travel.

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? - Epileptic cry - Confusion - Urinary incontinence - Body rigidity

Correct response: Confusion Explanation: In the postictal state (after the seizure), the patient is often confused, hard to arouse, and may sleep for hours. The epileptic cry occurs from the simultaneous contractions of the diaphragm and chest muscles that occur during the seizure. Urinary incontinence and intense rigidity of the entire body are followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction) during the seizure.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply. - Have the patient take a hot tub bath to allow muscle relaxation. - Apply warm compresses to the affected areas. - Assist with a rigorous exercise program to prevent contractures. - Demonstrate daily muscle stretching exercises. - Allow the patient adequate time to perform exercises

Correct response: Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Explanation: Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for? - Diarrhea - Lactose intolerance - Pruritus - Dyskinesia

Correct response: Dyskinesia Explanation: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome, characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.

A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis? - Risk for deficient fluid volume - Excess fluid volume - Risk for unstable blood glucose - Imbalanced nutrition: less than body requirements

Correct response: Excess fluid volume Explanation: A unique clinical feature of St. Louis encephalitis is the development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) with hyponatremia in 25% to 33% of affected patients; SIADH often results in profound fluid overload. Impaired nutrition and unstable blood glucose levels may occur.

A 55-year-old male patient has been admitted to the hospital with a gastrointestinal bleed, and the patient has just experienced a generalized seizure that may be attributable to alcohol withdrawal. When providing immediate care during the patient's seizure, what nursing diagnosis should be prioritized? - Acute confusion - Risk for impaired skin integrity - Acute pain - Impaired gas exchange

Correct response: Impaired gas exchange Explanation: Airway and breathing are priorities in any emergency situation, including seizures. These considerations would be prioritized over confusion, pain, and skin integrity.

A middle-aged woman has just received word that her recent diagnostic testing has resulted in a diagnosis of myasthenia gravis. The nurse who is contributing to this woman's care should be aware that she is experiencing signs and symptoms that are the result of what pathophysiological process? - Nerve demyelination - Inadequate action of acetylcholine - Loss of upper and lower motor neurons - Decreased levels of dopamine

Correct response: Inadequate action of acetylcholine Explanation: In myasthenia gravis, there is a reduction in the number of acetylcholine receptor sites because antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the neuromuscular junction. Demyelination causes multiple sclerosis, whereas low dopamine levels are implicated in Parkinson's disease. Amyotrophic lateral sclerosis (ALS) results from the loss of upper and lower motor neurons.

A 44-year-old woman has been admitted to the medical unit because of a recent exacerbation of multiple sclerosis. Which of the following nursing actions should be prioritized in this patient's care? - Reorient the patient to time and place during interactions. - Institute measures to reduce the patient's risk of falls. - Provide a liquid diet. - Implement universal infection control precautions.

Correct response: Institute measures to reduce the patient's risk of falls. Explanation: Involvement of the cerebellum or basal ganglia can produce ataxia (impaired coordination of movements) and tremor. This phenomenon, combined with muscle weakness, creates a risk of falls. Severe confusion is less common, and the patient does not normally have a greatly increased risk of infection. A liquid diet is not necessary

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following? A) Respiratory function B) Potential skin breakdown C) Cardiac function D) Cognition

A) Respiratory function - The most common reasons for hospitalization are dehydration and malnutrition, pneumonia, and respiratory failure; recognizing these problems at an early stage in the illness allows for the development of preventive strategies. In about 25% of patients, weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking, swallowing, and, ultimately, breathing occurs.

The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication? A) Impaired skin integrity B) Cognitive deficits C) Hemorrhage D) Autonomic dysfunction

Ans: D Feedback: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-Barr syndrome.

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? A) Cognitive declines B) Personality changes C) Contractures D) Difficulty in coordination

Ans: D Feedback: The primary symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease.

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of: - Visual disturbances and muscle weakness - Increasing forgetfulness and confusion - Tremors and muscle rigidity - Fatigue and respiratory difficulties

Correct response: Tremors and muscle rigidity Explanation: The cardinal signs of PD are tremor, rigidity, akinesia/bradykinesia, and postural disturbances.

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. - Opening the patient's jaw and inserting a mouth gag - Loosening constrictive clothing - Positioning the patient on his or her side with head flexed forward - Providing for privacy - Restraining the patient to avoid self injury

Correct response: Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy Explanation: During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck, and he tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? - Negative Brudzinski's sign - Positive Kernig's sign - Hyperactive patellar reflex - Sluggish pupil reaction

Correct response: Positive Kernig's sign Explanation: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig's sign, a positive Brudzinski's sign, and photophobia. Hyperactive patellar reflex and a sluggish pupil reaction are not common signs of meningitis.

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? - Semisolid food with thick liquids - Pureed food with water - Thin liquids only - Solid food with thin liquids

Correct response: Semisolid food with thick liquids Explanation: A semisolid diet with thick liquids is easier to swallow for a patient with swallowing difficulties than a solid diet. Thin liquids should be avoided. Pureed foods with water are not indicated for this patient.

The nurse is providing morning care for a male patient who is recovering from a head injury. The patient's right hand has begun twitching, and he is speaking unintelligibly. This patient has most likely experienced what type of seizure? - Tonic-clonic seizure - Simple partial - Complex partial - Absence seizure

Correct response: Simple partial Explanation: In simple partial seizures, only a finger or hand may shake, or the mouth may jerk uncontrollably. The person may talk unintelligibly, may be dizzy, and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness. In complex partial seizures, the person either remains motionless or moves automatically but inappropriately for time and place, or he or she may experience excessive emotions of fear, anger, elation, or irritability. Tonic-clonic seizures begin with rigidity (tonic phase), followed by repetitive clonic activity of all extremities characterized by stiffening or jerking of the body. Absence (petit mal) seizures involve short episodes of staring and loss of awareness.

Nursing students are reviewing information about Parkinson's disease in preparation for class the next day. The students demonstrate understanding of the material when they identify which of the following as a cardinal sign of this disorder? Select all that apply. - Rigidity - Postural instability - Intellectual decline - Bradykinesia - Tremor

Correct response: Tremor Rigidity Bradykinesia Postural instability Explanation: Cardinal signs of Parkinson's disease are tremor, rigidity, bradykinesia, and postural instability. Although mental status changes can occur over the course of the disease, intellect is usually not affected.

The nurse is planning the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis. What schedule would be most appropriate for the organization of diagnostic procedures for this patient? - All at one time, to provide a longer rest period - Before meals, to stimulate her appetite - In the morning, with frequent rest periods - Before bedtime, to promote rest

In the morning, with frequent rest periods. Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should be avoided at bedtime.

The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia

Ans: B Feedback: Bells palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus

4. A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action? A) Administer bronchodilators as ordered. B) Remind the patient of the importance of deep breathing and coughing exercises. C) Prepare to assist with intubation. D) Administer supplementary oxygen by nasal cannula.

Ans: C Feedback: For the patient with Guillain-Barr syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the patients oxygenation needs.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient? A) Maintaining the patients functional independence B) Providing health education C) Monitoring neurologic status closely D) Promoting mobility

Ans: C Feedback: Vigilant neurologic monitoring is a key aspect of caring for a patient who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication? -Reduction in the appearance of new lesions on magnetic resonance imaging (MRI) -Decreased muscle spasms in the lower extremities -Increased muscle strength in the upper extremities -Promotion of urinary continence

Decreased muscle spasms in the lower extremities Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. It is not used to promote continence or to increase strength. Avonex and Betaseron reduce the appearance of new lesions on the MRI.

A patient with Bell's palsy asks the nurse why she has to wear an eye shield at night. What would be the nurse's best response? - "A patient with Bell's palsy often can't close the eye, which causes insomnia." - "A patient with Bell's palsy needs an eye shield at night to prevent injury to the eye." - "A patient with Bell's palsy can't blink, so the eye shield keeps the eye moist." - "A patient with Bell's palsy needs extra coverage for their eye."

"A patient with Bell's palsy needs an eye shield at night to prevent injury to the eye." Frequently, the eye does not close completely and the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation, corneal abrasion, and ulceration may occur. Distortion of the lower lid alters the proper drainage of tears. To prevent injury, the eye may be covered with a protective shield at night. The eye patch may abrade the cornea, however, because there is some difficulty in keeping the partially paralyzed eyelids closed. Eye ointment may be applied at bedtime to promote adherence of the eyelids to prevent injury during sleep. Artificial tears are typically instilled to maintain eye lubrication. The patient can be taught to close the paralyzed eyelid manually before going to sleep. Wrap-around sunglasses or goggles may be worn during the day to decrease normal evaporation from the eye.

After suffering a fall, an 81-year-old woman with Alzheimer's disease (AD) is being treated in the hospital. Which of the following measures should be implemented in an effort to support the patient's cognitive function? A) Maintain consistent, predictable routines whenever possible. B) Provide an engaging, high-stimulation environment. C) Establish clear consequences for aggressive behavior. D) Ensure that the patient has a different care provider each day.

A) Maintain consistent, predictable routines whenever possible. - A calm, predictable environment helps people with AD interpret their surroundings and activities. Environmental stimuli are limited, and a regular routine is established. A quiet, pleasant manner of speaking, clear and simple explanations, and use of memory aids and cues help minimize confusion and disorientation and give patients a sense of security. Behavioral problems, such as agitation and psychosis, can be managed by behavioral and psychosocial therapies. Providing an environment that is controlled and stable can help with behavior problems.

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication? A) Increased muscle strength B) Decreased pain C) Improved GI function D) Improved cognition

Ans: A Feedback: The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue. The drug is not intended to treat pain, or cognitive or GI functions.

A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A) Serial assessments of hemoglobin levels B) Blood glucose monitoring C) Close monitoring of fluid balance D) Assessment of pain along dermatomes

Ans: C Feedback: A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important to monitor the patients intake and output closely.

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan? A) Encourage patient to void every hour. B) Order a low-residue diet. C) Provide total assistance with all ADLs. D) Instruct the patient on daily muscle stretching.

Ans: D Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.

A patient with herpes simplex virus (HSV) encephalitis has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? - Cyclosporine (Neoral) - Acyclovir (Zovirax) - Cyclobenzaprine (Flexeril) - Ampicillin (Principen)

Correct response: Acyclovir (Zovirax) Explanation: Acyclovir (Zovirax), an antiviral agent, is the medication of choice in HSV treatment. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin is an antibiotic.

A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply. - Changes in vision - Seizures - Hemiparesis - Expressive aphasia - Nystagmus

Correct response: Hemiparesis Seizures Expressive aphasia Explanation: Signs and symptoms of a frontal lobe abscess include hemiparesis, expressive aphasia, seizures, and frontal headache. Vision changes are associated with a temporal lobe abscess. Nystagmus is a sign of a cerebellar abscess.

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure? - IV lidocaine - IV phenobarbital - IV diazepam - Oral phenytoin

Correct response: IV diazepam Explanation: Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur without full recovery of consciousness between attacks. Medical management of status epilepticus includes IV diazepam (Valium) and IV lorazepam (Ativan), given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.

A patient has been admitted to the intensive care unit (ICU) for the treatment of bacterial meningitis. The ICU nurse is aware of the need for aggressive treatment and vigilant nursing care because meningitis has the potential to cause what sequela? - Hydrocephalus - Glioma - Increased intracranial pressure (ICP) - Cerebrovascular accident (CVA)

Correct response: Increased intracranial pressure (ICP) Explanation: Increased ICP is a significant risk in patients being treated for meningitis. This infection does not cause brain tumors, hydrocephalus, or CVA.

The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? - The patient should attempt to maintain prediagnosis levels of activity and mobility. - The patient should perform frequent physical activity but avoid becoming fatigued. - The patient should prioritize energy conservation and remain on bed rest if possible. - The patient should perform exercises that are brief but high-intensity.

Correct response: The patient should perform frequent physical activity but avoid becoming fatigued. Explanation: The patient is encouraged to work and exercise to a point just short of fatigue. Very strenuous physical exercise is not advisable because it raises the body temperature and may aggravate symptoms. The patient is advised to take frequent short rest periods, preferably lying down. Extreme fatigue may contribute to the exacerbation of symptoms. It is unrealistic to expect the patient to maintain prediagnosis levels of activity.

An infusion of phenytoin (Dilantin) has been ordered for a patient whose brain tumor has just caused a seizure. The patient has been receiving D5W at 100 mL/hour to this point and has only one IV access site at this point. How should the nurse prepare to administer this drug to the patient? - Administer the drug orally due to the risk of precipitation. - Thoroughly flush the patient's IV with normal saline. - Mix the phenytoin in a 50 mL mini-bag of D5W. - Saline lock the patient's IV and wait 15 minutes before administering phenytoin.

Correct response: Thoroughly flush the patient's IV with normal saline. Explanation: The rate of Dilantin administration is no faster than 50 mg/min in normal saline solution, since the drug precipitates in D5W. If the preexisting solution contained dextrose, the nurse flushes the IV line with normal saline before administering the medication.

A client with meningitis has a history of seizures. Which should the nurse do to safely manage the client during a seizure? Select all that apply. - Turn the client to the side. - Physically restrain the client's movements. - Provide verbal reassurance. - Inspect the oral cavity and teeth.

Correct response: Turn the client to the side. Provide verbal reassurance. Explanation: Turning client to the side will allow accumulated saliva to drain from the mouth. The person may not be able to hear you while unconscious, but verbal assurances will help as the person is regaining consciousness. Physically restraining a client during a seizure increases the potential for injuries. Inspection of oral cavity occurs after a generalized seizure and not during a seizure.

The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient? - Reorienting the patient to person, time, and place - Using the incentive spirometer as prescribed - Limiting free water to 1 L per day - Maintaining the patient on bed rest

Correct response: Using the incentive spirometer as prescribed Explanation: Respiratory function can be maximized in GBS with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré does not affect cognitive function or level of consciousness. Fluid restriction is not indicated.

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

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.

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man? A) "If you're consistent with taking your medication, you might not experience symptoms for several more years." B) "This medication can cure Parkinson's disease, but this is not necessarily the case for everyone." C) "The beneficial effects of this medication usually increase over time, so you may not get maximum relief for a few years." D) "This medication helps significantly but the benefits tend to decrease over time."

D) "This medication helps significantly but the benefits tend to decrease over time." The beneficial effects of levodopa are most pronounced in the first few years of treatment. Benefits begin to wane and adverse effects become more severe over time. Confusion, hallucinations, depression, and sleep alterations are associated with prolonged use. Levodopa is usually administered in combination with carbidopa (Sinemet), an amino acid decarboxylase inhibitor, which helps to maximize the beneficial effects of levodopa. Within 5 to 10 years, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements), including facial grimacing, rhythmic jerking movements of the hands, head bobbing, chewing and smacking movements, and involuntary movements of the trunk and extremities.

23. An elderly female resident of a long-term care facility has a diagnosis of Alzheimer's disease (AD). The resident is visibly anxious and is insisting to the nurse that she needs to "take care of my babies." How should the nurse respond to the resident's statement? A) Reorient the resident to the fact that she does not have young children. B) Ask the resident questions about her children to help her realize that her children are now adults. C) Ignore the resident's statement and return to the room later. D) Engage the resident in a conversation about a different topic.

D) Engage the resident in a conversation about a different topic. Trying to reason with people with AD and using reality orientation only increases their anxiety without increasing function.