Module 7

The diagnosis of dementia is based on assessment of the presenting problem. The American Academy of neurology practice parameters recommend screening for which disorder when assessing a client for dementia?

Depression -screening for depression, vitamin B 12 deficiency, normal pressure hydrocephalus, and hypothyroidism are appropriate

A client sustained an injury to the brain stem. What is the most important assessment perameter that the nurse should perform for the client?

Depth of respirations -The brainstem controls many functions. The medulla oblongata contains the nuclei for the cranial nerves and has centers that control and regulate respiratory function, heart rate and force, and blood pressure

A seven-year-old mother states that the child just zones out for several seconds and licks her lips. She states it happens at least 4 to 6 times an hour. She states that it has been happening for about one year. After several seconds of lip licking her daughter seems normal again. What type of seizure disorder is most likely?

Generalized absence seizure -in an absence seizure there is no tonic clonic activity. There is a sudden brief lapse of consciousness with blinking, steering, lip smacking, or hand movements that resolve quickly to full consciousness. It is easily mistaken for daydreaming or ADD.

The cranial nerve that has sensory fibers for taste and fibers that result in the gag reflex is the

Glossopharyngeal -The glossopharyngeal nerve contains sensory fibers for taste on posterior third of tongue and sensory fibers of the pharynx that result in the gag reflex when stimulated

A client who is injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this clients injury?

Glossopharyngeal (IX)

A nurse is reviewing a clients health record while interviewing her. The nurses in the clients record a score of 3+ on the biceps reflects test from her previous visit. The nurse understand that this finding indicate which of the following?

Increased or brisk, but not pathologic -Normal reflex scores range from 1+ (present but decreased) to 2+ (normal) to 3+ (increased or brisk, but not pathologic). Absent or markedly decreased deep tendon reflexes are rated zero. They occur when a component of the lower motor neurons or reflex arc is impaired and may be seen with spinal cord injuries. Markedly hyper active deep tendon reflexes are rated 4+ and may be seen with lesions of the upper motor neuron's and when the higher cortical levels are impaired

Which is the central focus of persecutory delusions?

Injustice that must be remedied by legal action -The focus of persecutory delusions is often on some injustice that must be remedied by legal action. Clients often see satisfaction by repeatedly appealing to courts and other government agencies.

37-year-old insurance agent reports trembling hands. She says for the past three months when she tries to use her hands to fix her hair or cook they shake badly. She doesn't feel particularly nervous when this occurs. She admits to having recent fatigue, trouble with vision, and difficulty maintaining bladder control she denies tobacco, alcohol or drug abuse. On examination, when she tries to reach for a pencil to fill out the form she has obvious tremors in her dominant hand. What type of tremors is most likely?

Intention tremor -intention tremors are absent at rest or in a postural position and only occur with intentional movement of the hands. This is seen in cerebellar disease (stroke or alcohol use) Or in multiple sclerosis. This clients trimmer, fatigue, bladder problems, and visual problems as suggest multiple sclerosis.

A client who experienced serious and repeated traumas has been diagnosed with dissociative identity disorder after being rescued from an abuser. Before caring for this client, the nurse should be prepared for

wide variations in the personality that the client exhibits. -dissociative identity disorder is characterized by the presence of more than one distinct personality or identity state.

Which are cognitive client outcomes? SATA

-The client lists the side effects of digoxin -The client describes how to perform progressive muscle relaxation -The client identify signs and symptoms of hypoglycemia

The nurse is caring for a client undergoing cognitive behavior therapy for obsessive compulsive disorder. How does the cognitive model describe the clients thought process? SATA

-The client wants to control own thoughts -The client has intolerance for uncertainty -The client over estimates the threats caused by the thoughts -according to the cognitive model, The person believes that if I think it will happen. Therefore, the client wants to control the clients own thoughts. The client tries to be perfect and has in tolerance for uncertainty. The client feels threatened by the thoughts.

A 70-year-old woman is brought to the emergency department by her daughter who noticed her mother has been experiencing intermittent confusion, uncoordinated movements and visual disturbances over the past several months. What should the nurse asked to best determine the cause of the symptoms? SATA

-What medication does your mother currently taking? -does your mother drink alcohol? -these symptoms are characteristic of Wernicke Korsakoff syndrome, which is associated with alcohol abuse.

A client has a significant history of congestive heart failure. What should the nurse specifically access during the clients semi annual cardiology examination? SATA

-examine the clients neck for distended veins -Monitor the client for signs of lethargy or confusion -during a head to toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultate apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion.

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a comma. What is the level of serum sodium at which a client can experience the side effects?

114 -Hyponatremia occurs when the serum sodium level dips below 135. When serum sodium levels fall below 115, mental confusion, muscle weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, personality changes, convulsions, or, can occur.

What should the nurse assessed to test the function of the occipital lobe?

Ability to read -To assess the function of the occipital lobe, the nurse should test the ability to read. To assess the function of the parietal lobe, the nurse should test for tactile sensation. The function of the temporal lobe is assessed by testing for impulses from the ear. Assessment of the frontal lobe is done by testing the clients communication.

Which of the following neurotransmitters are Deficient in myasthenia gravis?

Acetylcholine -A decrease in the amount of acetylcholine causes myasthenia gravis. A decrease of serotonin leads to depression. Parkinson's disease is caused by a depletion of dopamine. Decreased levels of GABA may cause seizures.

A nurse is explaining cognitive development in children to a client, with the help of Piaget's theory of cognitive development. What would be the best explanation by the nurse about the formal operations level of cognitive development?

After age 12 children can think in the abstract, including complex problem-solving

A client diagnosed with schizophrenia has been prescribed clozapine. Which is a potentially fatal side effects of this medication?

Agranulocytosis -agranulocytosis is manifested by a failure of the bone marrow to produce adequate white blood cells. Neuroleptic malignant syndrome is a life-threatening reaction to neuroleptic medication that requires immediate treatment.

A female clients physician orders a low-dose antipsychotic to manage her acute agitation. Her daughter states that her mother is improved but her cognitive functions are the same, if not worse, then last month. What is the best explanation for this development?

Antipsychotics do not improve memory loss and may further impair cognitive functioning -if antipsychotic drugs are used to control acute agitation in older adults, they should be used in the lowest effective dose for the shortest effective duration. If the drugs are used to treat dementia, they may relieve some symptoms but they do not improve memory loss and may further impair cognitive functioning

A nurse is testing a clients corneal reflects but notices that the reflex appears to be reduced. The client is otherwise alert and oriented, with no signs of neurologic degeneration. What is an appropriate action by the nurse?

Ask the client about the presence of contact lenses -The corneal reflex is done to assess the sensory portion of cranial nerve V (Trigeminal). If the client has an intact nervous system, the nurse should ask about the presence of contact lenses because they can caused a reflex to be absent or reduced. Touching the cornea with a small piece of cotton is how the test is performed.

The spouse of a client admitted to the hospital after a motor vehicle accident reports to the nurse that the client has become very drowsy. The nurse should

Assess the client for additional signs and symptoms of increased intercranial pressure -decreased alertness and drowsiness can be an early sign of increased intercranial pressure, the nurse should assess for additional signs and symptoms. Once the assessment is complete the nurse should contact the physician as needed.

A nurse observes a clients gait and notes it to be wide-based and staggering. Then romberg test results were positive. The nurse recognize this as what type of abnormal gait?

Cerebellar ataxia -Cerebellar ataxia is recognized by the wide-based and staggering gait. The Romberg test will be positive. This gate can be seen in person with cerebellar disease or alcohol or drug intoxication.

A nurse is assessing and elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this clients cognitive changes?

Decreased acetylcholine level -A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Coline acetyltransferase, and enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia.

The nurse is caring for a client in the hospital and identifies the client to be experiencing a cute confusion after cardiac surgery. The nurse recognizes this as what?

Delirium -Delirium in an acute onset of confusion related to an underlying cause such as medication, disease or traumatic event. Dementia occurs over time, amnesia is a loss of memory and hypoxia may be a cause of delirium.

A nurse is preparing to teach an eight year old child recently diagnosed with diabetes how to give an insulin injection. Which is the best technique for the nurse to use?

Demonstration The purpose of demonstration is to show how the procedure actually is done. Having to imagine steps is a little different than reading about them. School-age children learn best by demonstration.

A client with Alzheimer's disease is forgetful and has started to lose interest in social activities. Which treatment routine would be beneficial for the client?

Donepezil -The cholinesterase inhibitor or donepezil has been effective in slowing cognitive decline in early stages of AD. Memantine is used for moderate to severe AD.

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?

Dysarthria

When testing the biceps reflex, what type of response should the nurse expect if normal?

Elbow flexes and muscle contracts -to elicit the biceps reflex, the nurse should ask the client to partially bend the arm at the elbow with the palm up. The nurse place is the thumb over the biceps and strikes the time with the reflex hammer. The normal finding with this reflex is the elbow flexes and contraction of the biceps muscle occurs.

A client is being released from the inpatient psychiatric unit with a diagnosis of schizophrenia and treatment with antipsychotic medication. After teaching the client and family about managing the disorder, The nurse determines that the education was effective when they state that which should be reported immediately?

Elevated temperature -clients receiving antipsychotic therapy need to be alerted to the potential for complications, including neuroleptic malignant syndrome, a life-threatening condition that can occur with antipsychotic agents. This syndrome is manifested by severe muscle rigidity and elevated temperature that can rapidly accelerate.

A client with Alzheimer's disease mumbles incoherently and rambles in a confused manner. To help redirect the clients attention, the nurse should encourage the client to

Fold towels and pillowcases -folding towels and pillowcases is a simple activity that redirects the clients attention. Also, because this activity is familiar, the client is likely to perform it successfully.

The portion of the brain that rims the surfaces of the cerebral hemispheres forming the cerebral cortex is the

Gray matter -The lobes are composed of a substance known as gray matter, which mediate higher level functions such as memory, perception, communication, and initiation of voluntary movements. Consisting of aggregations of neuronal cell bodies, gray matter rims the services of the cerebral hemispheres, forming the cerebral cortex.

Which condition is an early manifestation of HIV and cephalopathy?

Headache -Early manifestations of HIV encephalopathy include headache, memory deficits, difficulty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia. Later stages include hyperreflexia, a vacant stare, and hallucinations.

An ambulance brings an older adult client to the ED. The clients daughter found the client on the floor of the house; the client is almost unresponsive. It is unknown how long the client was on the floor. When performing in a cute assessment on the client, which of the following made a healthcare team omit?

Health history

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

A nurse is educating a group of middle-aged adults on aging. What information should the nurse include in the teaching?

How old do you feel will be determined by your physical and cognitive abilities -The physical health and cognitive abilities of older adults are directly related to quality of life and how old one really feels

The nurse is caring for a client who is exhibiting signs of stress. Which cognitive symptoms associated with stress does the nurse recognize?

Impaired concentration -impaired concentration is consistent with a cognitive symptom associated with stress. Difficulty falling asleep and lack of interest in sex are physical symptoms associated with stress, and angry outbursts are emotional symptoms associated with stress

When describing the difference between schizoaffective disorder and schizophrenia, the nurse would address which is associated with SAD?

Increased mood responses -clients with SAD have many similar responses to their disorder as people with schizophrenia, with one exception. These clients have more "mood" responses and are very susceptible to suicide

In working with the individual and family, which is the most accurate statement the nurse can make in order to teach the client and family about schizophrenia?

Individuals with schizophrenia do have differences in brain structure and function that causes a variety of symptoms such as lack of motivation and hearing voices

The unlicensed assistive personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

Initiate use of a bed alarm

The nurse assesses the motor system as part of the Full neurological examination. In order to effectively assess their system, which of the following instructions should be given to the client?

Instruct the client to flex and extend the right elbow

Client reports that she is experiencing a tremor when she reaches for things. This worsens as she near the target. When the examiner asked the client to hold out her hands, no tremor is apparent. What type does this most likely represent?

Intention -because it worsens as the target is approached, this represents an intention tremor. In this client, one may suspect cerebellar pathway disease, possibly from multiple sclerosis. One could also look for an intra-nuclear ophthalmoplegia. A postural tremor occurs when a certain position is maintained; resting tremors occur with diseases such as Parkinson's.

The nurse assesses a client with renal failure for and cephalopathy caused by uremia. Which clinical manifestation will the nurse likely find?

Loss of recent memory and inattention -reductions in alertness and awareness are the earliest and most significant indications of uremic and cephalopathy. These are often followed by an inability to fix attention, loss of recent memory, and perceptual errors in identifying people and objects. Chest pain and friction rub can result from uremia related pericarditis.

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? SATA

Mental status, cranial nerves, motor system, sensory system, reflexes

A nurse expect to find which signs and symptoms in a client experiencing hypoglycemia?

Nervousness, diaphoresis, and confusion

A client has been prescribed quetiapine for delusional disorder. In teaching the client about this medication, the nurse must be certain to include which information?

One of the common side effects is dry mouth.

A client is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

Patellar

The nurse is assessing a client exhibiting dystonic movements. The nurse should review the clients medication's from home to check whether he is taking which medications that may cause the dystonia?

Psychiatric medication -dystonia is commonly due to the use of psychiatric medication, resulting in slow, involuntary movement of the trunk and larger muscles. These movements may also be accompanied by twisted postures.

Following focal seizures that have damaged the dominant hemisphere of a clients auditory association cortex, the nurse may observed the client displaying

Receptive aphasia -damage to the auditory association cortex, especially if bilateral, result in deficiencies of sound recognition and memory, auditory agnosia. If the damage is in the dominant hemisphere, speech recognition can be affected, sensory or receptive aphasia.

It is evident that a client has entered Piaget's stage of formal operations when the client

Speaks about a recent ballad as being reflective of the clients life story

Sensations of temperature, pain, and crude and light touch are carried by way of the

Spinothalamic tract

21 year old student complaining of back pain and tripping when he walks. He states it started three months ago with back and buttock pain and has since progressed to feeling weak in his left leg. He denies any bowel or bladder symptoms. On examination he is tender over the lumbar spine and he has a positive straight leg raise on the left. His Achilles tendon reflex is decreased on the left. While watching his gate the nurse notices that the client hast to pick his left foot up high in order not to trip. What abnormality of gate does he most likely have?

Steppage gait -steppage gait is associated with foot drop, usually secondary to a lower motor neuron disease. This is often seen with a herniated disc.

Which assessment findings in a client who is suspected of having a delusional disorder would be suggestive of a diagnosis of schizophrenia?

The client experiences frequent and sustained hallucinations -The presence of prominent and sustained hallucinations is suggestive of schizophrenia rather than delusional disorder. Non-bizarre delusions are associated with delusional disorder, and people with either diagnosis lack insight.

A 55-year-old client was admitted to the psychiatric unit after an incident in a department store in which the client accused a sales clerk of following the client around the store and stealing the clients keys. The client was subdued by the police after destroying a window display because the voices had told the client it was evil. As the nurse approached the client, the client says "you're all out to get me, and you're one of them. They're rostoputians and grog babies here." This demonstrates what?

Suspiciousness and neologisms

What should the nurse assess to test the function of the parietal lobe?

Tactile sensation

The nurse is examining a two year old girl for speech and language development. Which finding would suggest a delay in speech development?

The child does not use the names of familiar objects -by 24 months most children will name objects familiar to them in their daily lives. Not doing so is strong evidence that a speech delay may exist.

The client who scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

To reduce or prevent edema of the legs and feet -made of elastic material, anti-embolism stockings are designed to reduce or prevent Adema of the legs or feet by promoting venous return. They do this by increasing arterial and venous blood circulation to the legs and feet.

Which statements characterizes the major difference between the typical and atypical antipsychotic medication's?

Typical antipsychotics most often relieve positive symptoms but do not have a significant impact on negative symptoms -traditional antipsychotics treat the positive symptoms of schizophrenia such as hallucinations and delusions. Atypical antipsychotics relieve both the positive and the negative symptoms such as apathy, abolition, social withdrawal.

A nurse is assessing a two year olds language development. What with the nurse expect to assess?

Use of a two word noun verb sentence -A two-year-old should be able to say a two word sentence that consists of a noun and a verb. A 15-month-old can say 4 to 6 words. A 30 month old knows his full name and can't name one color.

Which is a non-neurologic side effect of antipsychotic medications?

Weight gain

Abnormalities in which lobe is believed to be associated with schizophrenia?

frontal

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, sleep, and the anterior and posterior pituitary, the autonomic nervous system, and emotions and maintains overall autonomic control?

hypothalamus

The Glasgow coma scale measures the level of consciousness and clients who are at high risk for a rapid deterioration of the nervous system. A score of 13 indicates

some impairment -The points associated with the Glasgow coma scale are determined to assess levels of consciousness and coma. Points are allotted for each of the three areas; eye-opening, verbal response and motor responses. A score of 13 indicates some impairment.

Where do the cell bodies of the lower motor neurons lie?

spinal cord -lower motor neurons have cell bodies in the spinal cord, termed anterior horn cells; their axons transmit impulses through the anterior roots and spinal nerves into peripheral nerves, terminating at the neuromuscular junction.