Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? A.) "Have you experienced any viral infections in the last month?" B.) "Have you experienced any ptosis in the last few weeks?" C.) "Have you had difficulty with urination in the last 6 weeks?" D.) "Have you developed any new allergies in the last year?"

Answer: A.) "Have you experienced any viral infections in the last month?" Rationale:An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

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? A.) Accept the patient's behavior and do not take it personally. B.) Request that the patient be cared for by another nurse. C.) Discontinue the bath and resume it later. D.) Explain that the client is getting good care.

Answer: A.) Accept the patient's behavior and do not take it personally. Rationale: 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.

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

Answer: A.) Assessing respiratory effort Rationale: 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 plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

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? A.) Facial pain in the areas of the fifth cranial nerve B.) Hyporeflexia and weakness of the lower extremities C.) Ptosis and diplopia D.) Fatigue and depression

Answer: A.) Facial pain in the areas of the fifth cranial nerve

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

Answer: A.) Headache and nuchal rigidity Rationale: 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.

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? A.) Initiate isolation precautions. B.) Ensure the family receives prophylaxis antibiotic treatment. C.) Administer prescribed antibiotics. D.) Apply a cooling blanket.

Answer: A.) Initiate isolation precautions. Rationale: 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.

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? A.) Muscle weakness and hyporeflexia of the lower extremities B.) Fever and cough C.) Hyporeflexia and skin rash D.) Ptosis and muscle weakness of upper extremities

Answer: A.) Muscle weakness and hyporeflexia of the lower extremities

The most common cause of cholinergic crisis includes which of the following? A.) Overmedication B.) Infection C.) Undermedication D.) Compliance with medication

Answer: A.) Overmedication Rationale; 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 assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? A.) Positive Kernig's sign B.) Negative Brudzinski's sign C.) Positive Romberg sign D.) Hyper-alertness

Answer: A.) Positive Kernig's sign Rationale: A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.

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

Answer: A.) Providing palliative care Rationale: 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.

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? A.) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. B.) Suggest applying cool compresses on the face several times a day to tighten the muscles. C.) Inform the patient that the muscle function will return as soon as the virus dissipates. D.) Tell the patient to smile every 4 hours.

Answer: A.) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

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? A.) Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. B.) After administration of the medication, there will be no change in the status of the ptosis or facial weakness. C.) The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. D.) Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.

Answer: A.) Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Rationale: 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 who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate? A.) Encourage the client to close his eyes. B.) Alternatively patch one eye every 2 hours. C.) Turn out the lights in the room. D.) Instill artificial tears.

Answer: B.) Alternatively patch one eye every 2 hours. Rationale: 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 drug should be available to counteract the effect of edrophonium chloride? A.) Prednisone B.) Atropine C.) Azathioprine D.) Pyridostigmine bromide

Answer: B.) Atropine Rationale: 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 assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? A.) Numbness B.) Diplopia and ptosis C.) Patchy blindness D.) Loss of proprioception

Answer: B.) Diplopia and ptosis Rationale: The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the 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

Answer: B.) Intubation tray and suction apparatus

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? A.) Negative Kernig's sign B.) Positive Brudzinski's sign C.) Increased intake D.) Hyper-alertness

Answer: B.) Positive Brudzinski's sign Rationale: A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

A frontal lobe brain abscess produces which manifestation? A.) Localized headache B.) Seizures C.) Ataxia D.) Nystagmus

Answer: B.) Seizures Rationale; A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache. A temporal lobe brain abscess is manifested by localized headache. A cerebellar abscess is manifested by ataxia and nystagmus.

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? A.) "I was sitting at home watching television." B.) "I was putting my shoes on." C.) "I was brushing my teeth." D.) "I was taking a bath."

Answer: C.) "I was brushing my teeth."

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

Answer: C.) "I will stretch daily as directed by the physical therapist." Rationale: 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.

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

Answer: C.) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." Rationale: 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 is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? A.) "You will have a steady and gradual decline in function." B.) "Your type of MS is the least common, making it difficult to manage." C.) "You must avoid stress and extreme fatigue, because these can trigger a relapse." D.) "You should take your medications only during times of relapse."

Answer: C.) "You must avoid stress and extreme fatigue, because these can trigger a relapse."

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A.) A disorder in which the body has too many immunoglobulins B.) A disorder in which histocompatible cells attack the immunoglobulins C.) A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" D.) A disorder in which the body does not have enough immunoglobulins

Answer: C.) A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"

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

Answer: D.) Within 24 hours after exposure

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

Answer: A.) Multiple sclerosis Rationale: 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 with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? A.) vegetables B.) ice cream C.) meat D.) white rice

Answer: A.) vegetables

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? A.) Multiple sclerosis B.) Creutzfeldt-Jakob disease C.) Parkinson disease D.) Huntington disease

Answer: B.) Creutzfeldt-Jakob disease

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

Answer: C.) Administer atropine to control the side effects of edrophonium.

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? A.) Ambenonium (Mytelase) B.) Pyridostigmine (Mestinon) C.) Edrophonium (Tensilon) D.) Carbachol (Carboptic)

Answer: C.) Edrophonium (Tensilon)

Which is the primary vector of arthropod-borne viral encephalitis in North America? A.) Birds B.) Spiders C.) Mosquitoes D.) Ticks

Answer: C.) Mosquitoes

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? A.) Musculoskeletal B.) Integumentary C.) Hepatic D.) Renal

Answer: D.) Renal

Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. - Pain - Fatigue - Spasticity - Aphasia - Depression - Numbness

Answer: - Pain - Fatigue - Spasticity - Depression - Numbness

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? A.) Facial distortion and pain B.) Hyporeflexia and weakness of the lower extremities C.) Ptosis and diplopia D.) Fatigue and depression

Answer: A.) Facial distortion and pain

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

Answer: B.) Tensilon test

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? A.) Bell's palsy B.) Trigeminal neuralgia C.) Migraine headache D.) Angina pectoris

Answer: B.) Trigeminal neuralgia

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? A.) Parkinson disease B.) Huntington disease C.) Creutzfeldt-Jakob disease D.) Multiple sclerosis

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

Answer: A.) "The paralysis caused by this disease is temporary." Rationale: 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.

Bell's palsy is a paralysis of which of the following cranial nerves? A.) Facial B.) Trigeminal C.) Optic D.) Otic

Answer: A.) Facial

A neurologic deficit is best defined as a deficit of the: A.) central and peripheral nervous systems with decreased, impaired, or absent functioning. B.) central nervous system that affects one body system. C.) central nervous system with absent functioning. D.) peripheral nervous system with decreased or impaired functioning.

Answer: A.) central and peripheral nervous systems with decreased, impaired, or absent functioning.

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

Answer: B.) Administer prescribed antibiotics.

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for A.) signs and symptoms of cardiac insufficiency. B.) signs of relapse. C.) signs of improvement in the patient's condition. D.) renal complications related to acyclovir therapy.

Answer: D.) renal complications related to acyclovir therapy. Rationale: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse, treatment with acyclovir should continue for up to 3 weeks.

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

Answer: A.) Antibodies are removed from the plasma.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? A.) Apply an eye patch to the right eye. B.) Exercise the right eye twice a day. C.) Administer eye drops as needed. D.) Place needed items on the right side.

Answer: A.) Apply an eye patch to the right eye.

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

Answer: A.) Speeds nerve impulse transmission Rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

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

Answer: B.) Herpes simplex virus (HSV)

Myasthenia gravis occurs when antibodies attack which receptor sites? A.) Serotonin B.) Dopamine C.) Acetylcholine D.) Gamma-aminobutyric acid

Answer: C.) Acetylcholine Rationale: 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.