Gero: Neurologic and Sensory

Which equipment would the nurse recommend to foster independence at home for an ambulatory client who has Parkinson disease? 1 A raised toilet seat 2 Side rails for the bed 3 Crutches for ambulation 4 A trapeze above the bed

1 A raised toilet seat A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which make it unsafe to use crutches.

Which explanation would the nurse provide a client who asks what a cataract is? 1 An opacity of the lens 2 A thin film over the cornea 3 A crystallization of the pupil 4 An increase in the density of the conjunctiva

1 An opacity of the lens A cataract is a clouding (opacity) of the crystalline lens or its capsule.

Which sense is likely to be lost by a client who has osteogenesis imperfecta? 1 Auditory acuity 2 Visual acuity 3 Smell perception 4 Touch perception

1 Auditory acuity Some genetic disorders, such as osteogenesis imperfecta and Down syndrome, lead to progressive hearing loss in adults. Familial tendency and some genetic conditions may cause visual impairment. Osteogenesis imperfecta typically does not cause loss of smell or touch perception.

Which clinical manifestations would the nurse expect for a client who has myasthenia gravis? 1 Blurred vision with episodes of vertigo 2 Tremors of the hands when lifting objects 3 Partial improvement of muscle strength with mild exercise 4 Involvement of distal muscles more than proximal muscles

1 Blurred vision with episodes of vertigo Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.

Which physical assessment findings would the nurse document on a client who is experiencing Cushing triad? Select all that apply. One, some, or all responses may be correct. 1 Bradycardia 2 Tachycardia 3 Irregular respirations 4 Systolic hypertension 5 Diastolic hypertension 6 Widening pulse pressure

1 Bradycardia 3 Irregular respirations 4 Systolic hypertension 6 Widening pulse pressure A client experiencing Cushing triad presents with bradycardia (with a full and bounding pulse), irregular respirations, systolic hypertension, and a widening pulse pressure. These clients do not experience tachycardia or diastolic hypertension.

A young man who sustained a spinal cord injury at the cervical level expresses concern about future sexual functioning. Which action would the nurse take? 1 Explain to the client that he likely will be able to have reflex penile erections. 2 Reassure the client that he will be able to have sexual intercourse and reproduce. 3 Arrange for the client to be informed by the health care provider that sexual performance is unlikely. 4 Discourage the client from forming sexual relationships because little pleasure will be possible.

1 Explain to the client that he likely will be able to have reflex penile erections. The reflex arc for sexual activity is intact; control of ejaculation is not. The ability to perform sexually is determined on an individual basis. There are many ways to fulfill sexual needs. Reassuring the client that he will be able to have sexual relationships with the ability to reproduce may provide false reassurance. The ability to function is determined on an individual basis.

A client who had a brain attack (cerebrovascular accident, CVA) frequently cries when family members visit. The family members report being upset by the crying. Which explanation for the client's behavior would the nurse provide? 1 Having difficulty controlling reactions 2 Demonstrating a premorbid personality 3 Mourning the loss of functional abilities 4 Conveying unhappiness about the situation

1 Having difficulty controlling reactions A common complication of a brain attack is an inability to control emotional affect; clients may be depressed or apathetic and have a lability of mood. There are no data to support the conclusion that the client is demonstrating a premorbid personality. There are no data to support the conclusion that the client is mourning the loss of functional abilities. There are no data to support the conclusion that the client is conveying unhappiness about the situation.

Which condition can cause a client severe pain after a cataract extraction? 1 Hemorrhage into the eye 2 Expected postoperative discomfort 3 Isolation from sensory deprivation 4 Eye pressure from the protective shield

1 Hemorrhage into the eye Acute postoperative pain is a sign of increased intraocular pressure and is caused by hemorrhaging; this is a medical emergency. Postoperative discomfort usually is minimal. Isolation and sensory deprivation will not occur because only one eye is patched. The shield may be slightly uncomfortable but will not cause severe discomfort.

Which intervention would the nurse perform first for the client admitted with a closed head injury and increased intracranial pressure (ICP)? 1 Place the head and neck in neutral alignment. 2 Obtain a prescription for 100 mg of pentobarbital IV. 3 Administer 1 g mannitol intravenously (IV) as prescribed. 4 Increase the ventilator's respiratory rate to 20 breaths/minute

1 Place the head and neck in neutral alignment. The nurse would first attempt nursing interventions such as placing the head and neck in alignment (neutral position) to facilitate venous return and thereby decrease ICP. If nursing measures prove ineffective, notify the health care provider, who may prescribe mannitol. The nurse would notify the health care provider for hyperventilation therapy or for pentobarbital. Hyperventilation is used only when all other interventions have been ineffective in decreasing ICP.

The nurse finds a client lying on the floor next to a wheelchair. The client states, "I was trying to get back to bed and slipped." Which action would the nurse take first? 1 Call the nurse manager to alert administration. 2 Arrange for the client to be examined by the in-house health care provider. 3 Complete an incident report to ensure documentation of the event. 4 Provide information about the incident to the client's primary health care provider.

2 Arrange for the client to be examined by the in-house health care provider.

Which physiological process can be corrected with a prescribed convex lens? 1 Constriction of the pupil 2 Convergence of images behind the retina 3 Descent of inverted images onto the retina 4 Presence of an unevenly curved retinal surface

2 Convergence of images behind the retina Hyperopia occurs when the eye does not refract enough light, which leads to the image converging behind the retina. This condition can be corrected with a convex lens in eyeglasses or contact lenses. Constriction of the pupil is a condition called miosis, which can be altered by using medications. Emmetropia is the perfect refraction of the eye, where images fall on the retina inverted and reversed left to right. Astigmatism is a refractive error caused by unevenly curved surfaces on the eye, especially the cornea, which may not require convex lenses.

Which clinical indicators would the nurse expect to identify when assessing a client with tic douloureux? Select all that apply. One, some, or all responses may be correct. 1 Multiple petechiae 2 Excruciating facial pain 3 Twitching of the mouth 4 Unilateral muscle weakness 5 Fine-motor tremors of the eyelid

2 Excruciating facial pain 3 Twitching of the mouth Tic douloureux, also referred to as trigeminal neuralgia, is an inflammation of the fifth cranial (trigeminal) nerve that innervates the midline of the face and head, which includes the mouth. Petechiae are minute subcutaneous hemorrhages; they are not present in this disorder. Pain, not weakness, occurs in this disease. Impairment of facial muscles occurs with Bell palsy. The third (oculomotor), not fifth, cranial nerve innervates the eyelid.

Which nursing intervention is anticipated for a client who has Guillain-Barré syndrome? 1 Providing a straw to stimulate the facial muscles 2 Maintaining ventilator settings to support respiration 3 Encouraging aerobic exercises to avoid muscle atrophy 4 Administering antibiotic medication to prevent pneumonia

2 Maintaining ventilator settings to support respiration Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

The nurse is conducting an assessment on a client brought to the emergency room after a motor vehicle accident. The client pulls his arms upward and inward in response to pain. The nurse recognizes that this response represents an injury to which area? 1 Pons 2 Midbrain 3 Brainstem 4 Frontal lobe

2 Midbrain Decorticate posturing is a sign of significant deterioration in a client's neurological status and is manifested by rigid flexing of elbows and wrists. This can represent an injury to the midbrain. Damage to the frontal lobe would affect motor function, problem solving, spontaneity, memory, language, initiation, judgment, impulse control, and social and sexual behavior. The pons (which is part of the brainstem) and brainstem help control breathing and heart rate, vision, hearing, sweating, blood pressure, digestion, alertness, sleep, and sense of balance. Damage to this area would manifest itself as abnormal responses in the areas listed

The nurse teaches a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? 1 Take a hot bath on a daily basis. 2 Rest in an air-conditioned room. 3 Increase the dose of muscle relaxants. 4 Avoid naps during the day

2 Rest in an air-conditioned room. Fatigue is a common symptom in clients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, the client must avoid extreme cold. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning frequent rest periods and naps can relieve fatigue.

Which intervention would the nurse use first for a client with the diagnosis of Guillain-Barré syndrome who is having difficulty expectorating respiratory secretions? 1 Auscultate for breath sounds. 2 Suction the client's oropharynx. 3 Administer oxygen via nasal cannula. 4 Increase enteral feeding fluids to thin secretions.

2 Suction the client's oropharynx. A patent airway is the priority. The client does not have the ability to deep-breathe and cough, so oropharyngeal suctioning can provide immediate relief from the secretions obstructing the airway. Auscultating for breath sounds when there is audible fluid in the upper airway takes time, and the upper airway noise of secretions will mask other breath sounds, but auscultation could be done after the oropharynx is suctioned. Oxygen administration will be useless if the airway is not patent. Increasing fluids to thin secretions may be helpful but will take hours.

While assessing the client, the nurse observes abnormal eye movement. The client reports dizziness when standing or walking. Which structure of the auditory system might be affected in this client? 1 tympanic membrane 2 vestibular system 3 auditory tube 4 cochlea

2 vestibular system Abnormal eye movement is seen in nystagmus. Dizziness when standing or walking may indicate vertigo in the client. These both manifest because of problems with balance, which is maintained by the vestibular system marked by B. The structure represented as A is the tympanic membrane, a part of the middle ear. Conductive hearing loss may occur if the tympanic membrane is affected. The structure represented as C is the auditory tube, which helps equalize atmospheric air pressure between the middle ear and throat and allows the tympanic membrane to move freely. Structure C is not associated with vertigo and nystagmus. The structure represented as D is the cochlea and is involved in the transmission of sounds. Hearing impairment may result if the cochlea is affected.

A client who is newly diagnosed with multiple sclerosis is obviously upset and asks, "Am I going to die?" Which response would the nurse make? 1 "Most individuals with your disease live a normal life span." 2 "Is your family here? I would like to explain your disease to all of you." 3 "The prognosis varies, as most individuals have remissions and exacerbations." 4 "Why don't you speak with your health care provider to get more details?"

3 "The prognosis varies, as most individuals have remissions and exacerbations." This is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you" avoids the client's question; the family did not ask the question. The response "Why don't you speak with your health care provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

Which intervention is useful in promoting comfort for the client experiencing a headache? 1 Massage 2 Heat therapy 3 Cold therapy 4 Relaxation strategies

3 Cold therapy Cold therapy is believed to be more effective than heat for a variety of painful conditions such as headaches. Massage can be useful for acute or chronic pain but is not specifically used to treat headaches. Heat therapy can be used for superficial or deep tissue pain, but not for the treatment of headaches. Relaxation techniques are used to enhance the effectiveness of other pain relief measures.

Which assessment finding is the client who has a tumor of the cerebellum likely to exhibit? 1 Repeated loss of consciousness 2 Absence of the knee-jerk reflex 3 Inability to execute smooth movements 4 Lack of voluntary muscle motion

3 Inability to execute smooth movements The cerebellum is involved in the synergistic control of muscle action; it functions to produce smooth, steady, coordinated, and efficient movements. The cerebrum, not cerebellum, is responsible for the level of consciousness. The brain is not involved in a simple reflex arc. The cerebrum, not cerebellum, is responsible for voluntary motor function.

Which finding would the nurse expect when assessing a client who has a vertebral fracture at the T1 level? 1 Difficulty breathing 2 Inability to move the lower arms 3 Normal biceps reflexes in the arms 4 Loss of pain sensation in the hands

3 Normal biceps reflexes in the arms The client will have normal biceps reflexes with a T1 injury. The nerves for arm innervation are at C4, which is above the injury level of T1. Diaphragm innervation is not affected by this injury; the diaphragm is innervated above C4. Innervation of muscles used to move the lower arms is not affected by this injury; these muscles are innervated above C7. Innervation for pain sensation of the hands is not affected by this injury; these nerves are innervated above C7.

A client with a diagnosis of polyarteritis nodosa asks the nurse for information about this disorder. Which information would the nurse include in the response? 1 Clients with this disease have an excellent prognosis with dietary changes. 2 The disorder affects males and females in equal numbers. 3 The disorder entails hypersensitivity, and the exact cause is unknown. 4 This disease affects only the kidneys and the retina of the eyes.

3 The disorder entails hypersensitivity, and the exact cause is unknown. An autoimmune response plays a role in the development of polyarteritis, although drugs and infections may precipitate the disorder. The disorder often is fatal, usually as a result of heart or renal failure. The disease affects men three times more often than women. Arteriolar pathologic processes can affect any organ or system.

The nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Which statement explains the nurse's rational? 1 Deep tendon reflexes have been lost. 2 There is partial transection of the cord. 3 There is damage above the sixth thoracic vertebra. 4 Flaccid paralysis of the lower extremities has occurred

3 There is damage above the sixth thoracic vertebra. The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

Which information would the nurse include about future treatment and precautions when teaching a client who has glaucoma? 1. Avoidance of cholinergics 2. Surgical replacement of lens 3. Continuation of therapy for life 4. Prevention of high blood pressure

3. Continuation of therapy for life Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of the lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.

Which instruction is important for the nurse to provide to the client after cataract surgery? 1 Remain flat for 3 hours 2 Eat a soft diet for 2 days 3 Breathe and cough deeply 4 Avoid bending from the waist

4 Avoid bending from the waist Bending increases intraocular pressure and must be avoided. Remaining flat for 3 hours and eating a soft diet for 2 days are not necessary. Coughing deeply increases intraocular pressure and is contraindicated.

Which injury is consistent with a client who has blood draining from the left ear and rhinorrhea after a motor vehicle crash? 1 Contusion 2 Concussion 3 Fractured nose 4 Basilar fracture

4 Basilar fracture A fracture at the base of the cranium can tear meninges, causing nasal leakage of cerebrospinal fluid (rhinorrhea) and bleeding from the ear. A bruise will not cause these responses. A severe jarring of the brain will not cause these responses. A nose fracture will not produce a clear drainage, and the ears will not be draining.

Which physiological response is the likely cause of a client developing hydrocephalus 2 weeks after cranial surgery for a ruptured cerebral aneurysm? 1 Vasospasm of adjacent cerebral arteries 2 Ischemic changes in the Broca speech center 3 Increased production of cerebrospinal fluid (CSF) 4 Blocked absorption of fluid from the arachnoid space

4 Blocked absorption of fluid from the arachnoid space Residual blood from the ruptured aneurysm may have blocked the arachnoid villi, interrupting the flow of CSF and resulting in hydrocephalus. Vasospasm is a protective response during the active bleeding process; it does not cause hydrocephalus. The Broca center is not directly affected; even if it were, there is no relationship to the development of hydrocephalus. The production of cerebrospinal fluid is not increased in this situation; increased production may result when there is a tumor of the choroid plexus.

Which recommendation would the nurse give to the client with trigeminal neuralgia? 1 Drink iced liquids. 2 Avoid oral hygiene. 3 Apply warm compresses. 4 Chew on the unaffected side.

4 Chew on the unaffected side. The client may avoid stimulating the involved trigeminal nerve and thus prevent pain by chewing on the unaffected side. Food and fluids that are too hot or too cold can precipitate pain. Although oral hygiene may initiate pain, it cannot be avoided. It can be modified to include rinsing the mouth or using a soft swab instead of a toothbrush. Warm compresses may precipitate pain.

Which rationale is related to the condition which is characterized by a milky, white-gray ring encircling the periphery of the cornea? 1 Increased rigidity of the iris 2 Lipid deposition in the sclera 3 Prolapse of fat into the eyelid tissue 4 Cholesterol deposition in the peripheral cornea

4 Cholesterol deposition in the peripheral cornea The condition inferred in the image is arcus senilis, which is characterized by a milky, white-gray ring encircling the periphery of the cornea. This occurs due to cholesterol deposits in the peripheral cornea. Increased rigidity of the iris may result in decreased pupil size. Lipid deposition in the sclera may result in a yellowish discoloration of the sclera. A prolapse of fat into the eyelid tissue may result in blepharochalasis manifested as excessive upper lid skin.

A client has dysarthria after a stroke. Which goal would the nurse include in the plan of care to address this problem? 1 Routine hygiene 2 Balanced nutrition 3 Prevention of aspiration 4 Effective communication

4 Effective communication Clients with dysarthria have difficulty communicating verbally, and an alternative means of communication may be indicated. Routine hygiene, liquid formula diet, and prevention of aspiration are important aspects of care, but they are not related to dysarthria. Dysphagia can lead to aspiration.

Which imaging technique is specific for Alzheimer disease? 1 Diffusion imaging (DI) 2 Magnetic resonance imaging (MRI) 3 Magnetic resonance angiography (MRA) 4 Magnetic resonance spectroscopy (MRS)

4 Magnetic resonance spectroscopy (MRS) In diseases such as Alzheimer disease, stroke, and epilepsy, the biochemical process in the brain is altered. Abnormalities in biochemical processes of the brain are diagnosed with MRS. DI is used to evaluate ischemia in the brain to determine the location and severity of a stroke. MRI involves taking multiple sets of images to determine normal and abnormal anatomy. MRA is used to evaluate blood flow and blood vessel abnormalities, such as arterial blockage, intracranial aneurysms, and arteriovenous malformations in the brain.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem? 1 Dehydration 2 Skin breakdown 3 Electrolyte imbalances 4 Urinary tract infections

4 Urinary tract infections Clients in the early stages of spinal cord damage experience an atonic bladder; the characteristics include the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.