Chapter 58: Chronic Neurologic Problems Harding: Lewis's Medical-Surgical Nursing, 11th Edition

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern?

"Epilepsy usually can be well controlled with medications." Rational: The nurse should inform the patient that most seizure disorders are controlled with medication. The other information may be necessary if seizures persist after treatment with antiseizure medications is implemented.

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following?

"I will lie down someplace dark and quiet when the headaches begin." Rational: It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines. It must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?

"Symptoms of MS are likely to improve during pregnancy." Rational: Symptoms of MS may improve during pregnancy. There is no increased risk for congenital defects in infants born of mothers with MS. Onset of labor is not affected by MS. MS symptoms will not worsen after pregnancy.

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL should the nurse administer?

2.4 Rational: With a concentration of 125 mg/2 mL, the nurse will need to administer 2.4 mL to obtain 150 mg of methylprednisolone.

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV. Rational: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. What should the nurse anticipate explaining to the patient?

Antiparkinsonian drugs Rational: The clinical diagnosis of Parkinson's is made when tremor, rigidity, akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?

Ask the patient to keep a headache diary. Rational: The initial nursing action should involve further assessment of precipitating causes of the headaches, quality, and location of pain. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

The nurse observes a patient ambulating in the hospital hall. The patient's arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first?

Assess the patient for a possible injury. Rational: The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the health care provider, and administration of antiseizure medications may also be appropriate actions, but the initial action should be assessment for injury.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?

Assist with active range of motion (ROM). Rational: ALS causes progressive muscle weakness. Assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

What should the nurse advise a patient with myasthenia gravis (MG) to do?

Complete physically demanding activities early in the day. Rational: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG. Muscle atrophy does not occur because although there is muscle weakness, they are still used.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

Diphenhydramine Rational: Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first?

Discuss the need to stop taking the acetaminophen. Rational: The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure?

Focal-onset Rational: The initial symptoms of a focal-onset seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder?

Genetic testing is an option for the children to determine their HD risk. Rational: Genetic testing is available to determine whether an asymptomatic person has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching?

How to draw up and administer injections of the medication? Rational: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles?

Inadequate nutrition Rational: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

Inquire about urinary tract problems. Rational: Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Inspect the oral mucosa. Rational: Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Patient has slight elevations in liver function test results. Rational: Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first?

Notify the patient's health care provider. Rational: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

After change-of-shift report, which patient should the nurse assess first?

Patient with myasthenia gravis who is reporting increased muscle weakness. Rational: Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

Place medications in the home medication organizer. Rational: LPN/VN education includes administration of medications. The other activities require RN education and scope of practice.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.)

Provide an elevated toilet seat. Cut patient's food into small pieces Place an armchair at the patient's bedside. Rational: Because the patient with Parkinson's disease has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's disease is a steadily progressive disease without acute exacerbations

Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis?

Respiratory effort Rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

Side rail pads Oxygen mask Suction tubing Rational: The patient is at risk for further seizures, and O2 and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Start the prescribed PRN O2 at 6 L/min. Rational: Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

Which intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping?

Suggest that the patient exercise regularly during the day. Rational: Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.

A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care?

Suggest that the patient rock from side to side to initiate leg movement. Rational: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

Teach the patient how to use the Credé method. Rational: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The patient had a recent acute myocardial infarction. Rational: Triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

The patient has increased serum creatinine. Rational: Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

Time and observe and record the details of the seizure and postictal state. Rational: Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?

Uncontrolled head movement Rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache?

Unilateral ptosis Rational: Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially?

acetaminophen (Tylenol) Rational: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.