ML Quiz Ch 69
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 killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" B. A disorder in which the body has too many immunoglobulins C. A disorder in which histocompatible cells attack the immunoglobulins D. A disorder in which the body does not have enough immunoglobulins
A
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? A. Neurovascular system B. Endocrine system C. Cardiovascular system D. Respiratory system
A
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? A. Avoid hot temperatures. B. Avoid physical activity. C. Avoid analgesic medication. D. Take moderate amounts of alcohol.
A
Which of the following is considered a central nervous system (CNS) disorder? A. Multiple sclerosis B. Bell's palsy C. Guillain-Barré D. Myasthenia gravis
A
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. Fatigue and depression D. Ptosis and diplopia
A
Nursing assessment findings reveal joint swelling and tenderness and a butterfly rash on the face. The nurse suspects which of the following? A. Ankylosing spondylitis B. Systemic lupus erythematous C. Fibromyalgia D. Scleroderma
B
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. Loss of proprioception D. Patchy blindness
B
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? A. Administer edrophonium chloride per orders. B. Ensure atropine is readily available. C. Assess facial weakness 5 minutes after injection. D. Document the results.
B
Bell's palsy is a paralysis of which of the following cranial nerves? A. Otic B. Optic C. Trigeminal D. Facial
D
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. Apply a cooling blanket. C. Administer prescribed antibiotics. D. Ensure the family receives prophylaxis antibiotic treatment.
A
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. Represents building block of nervous system C. Acts as chemical messenger D. Carries message to the next nerve cell
A
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. Angina pectoris B. Migraine headache C. Trigeminal neuralgia D. Bell's palsy
C
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. Carbachol (Carboptic) B. Ambenonium (Mytelase) C. Pyridostigmine (Mestinon) D. Edrophonium (Tensilon)
D
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? A. Ensure that client takes nothing by mouth. B. Assess for facial weakness. C. Assess visual acuity. D. Initiate seizure precautions.
D
A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take? A. Support the patient's neck through normal range of motion and evaluate stiffness. B. Flex the patient's thigh on his abdomen and assess the extension of the leg. C. Assess the patient's sensitivity to light. D. Help the patient flex his neck and observe for flexion of the hips and knees.
D
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 applying cool compresses on the face several times a day to tighten the muscles. B. Tell the patient to smile every 4 hours. C. Inform the patient that the muscle function will return as soon as the virus dissipates. D. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
D
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. Call the rapid response team because the patient is preparing to arrest. D. Administer atropine to control the side effects of edrophonium.
D
Myasthenia gravis occurs when antibodies attack which receptor sites? A. Serotonin B. Gamma-aminobutyric acid C. Dopamine D. Acetylcholine
D
The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include A. akathisia and dysphagia. B. muscle rigidity, memory impairment, and cognitive impairment. C. diplopia and bradykinesia. D. sensory disturbance, limb pain, and behavioral changes.
D
The diagnosis of multiple sclerosis is based on which test? A. Magnetic resonance imaging B. Evoked potential studies C. Neuropsychological testing D. CSF electrophoresis
A
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? A. Headache that is worse in the morning B. Ptosis that is more pronounced at the end of the day C. Diplopia that is constant D. Nuchal rigidity
A
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. "It must be hard to accept the permanency of your paralysis." B. "The paralysis caused by this disease is temporary." C. "You'll first regain use of your legs and then your arms." D. "You'll be permanently paralyzed; however, you won't have any sensory loss."
B
Which drug should be available to counteract the effect of edrophonium chloride? A. Pyridostigmine bromide B. Atropine C. Azathioprine D. Prednisone
B
A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? A. Use a footboard and trochanter rolls. B. Change body position every 2 hours. C. Help the client perform range-of-motion (ROM) exercises every 8 hours. D. Use pressure-relieving devices when the client is in bed or in a wheelchair.
C
A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms A. are primarily associated with infection with Coccidioides immitis and Aspergillus. B. indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures. C. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. D. indicate renal toxicity and a worsening condition.
C
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. The thymus gland is removed. B. Mestinon therapy is initiated. C. Antibodies are removed from the plasma. D. Immune globulin is given intravenously.
C
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. Therapy is not necessary prophylactically and should only be used if the person develops symptoms. C. Within 24 hours after exposure D. Within 72 hours after exposure
C
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 had difficulty with urination in the last 6 weeks?" B. "Have you experienced any ptosis in the last few weeks?" C. "Have you experienced any viral infections in the last month?" D. "Have you developed any new allergies in the last year?"
C
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? A. Exercise the right eye twice a day. B. Administer eye drops as needed. C. Apply an eye patch to the right eye. D. Place needed items on the right side.
C
Which nursing intervention is the priority for a client in myasthenic crisis? A. Preparing for plasmapheresis B. Administering intravenous immunoglobin (IVIG) per orders C. Assessing respiratory effort D. Ensuring adequate nutritional support
C
The most common cause of cholinergic crisis includes which of the following? A. Compliance with medication B. Undermedication C. Infection D. Overmedication
D
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. Hyper-alertness B. Negative Brudzinski's sign C. Positive Romberg sign D. Positive Kernig's sign
D
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? A. No one with Guillain-Barre syndrome recovers completely. B. Usually 100% of clients recover completely. C. Only a very small percentage (5% to 8%) of clients recover completely. D. Approximately 60% to 75% of clients recover completely.
D
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? A. Gastrointestinal B. Urinary C. Skin D. Respiratory
D
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis? A. Maintaining hemodynamic stability and adequate cardiac output B. Preventing muscular atrophy C. Preventing renal insufficiency D. Controlling seizures and increased intracranial pressure
D
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase? A. reporting changes to the physician B. destabilizing client's condition C. preventing further neurologic damage D. assessing vital signs frequently
C
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for A. signs of improvement in the patient's condition. B. renal complications related to acyclovir therapy. C. signs and symptoms of cardiac insufficiency. D. signs of relapse.
B
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? A. Decreased pulse rate, respirations of 20 breaths/minute B. Increased pulse rate, adventitious breath sounds C. Decreased pulse rate, abdominal breathing D. Increased pulse rate, respirations of 16 breaths/minute
B
Which diagnostic test is used for early diagnosis of HSV-1 encephalitis? A. Magnetic resonance imaging (MRI) B. Polymerase chain reaction (PCR) C. Electroencephalography (EEG) D. Lumbar puncture (LP)
B
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. Huntington disease B. Multiple sclerosis C. Parkinson disease D. Creutzfeldt-Jakob disease
B
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? A. Preparing for organ donation B. Providing palliative care C. Administering amphotericin B D. Initiating isolation procedures
B
Which of the following is the first-line therapy for myasthenia gravis (MG)? A. Deltasone (Prednisone) B. Lioresal (Baclofen) C. Azathioprine (Imuran) D. Pyridostigmine bromide (Mestinon)
D
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing: A. infection. B. choking. C. falls. D. complications.
D