review5

1 Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1.Observe the client demonstrating the transfer technique. 2.Start a restorative nursing program before an injury occurs. 3.Seize the opportunity to discuss potential nursing home placement. 4.Determine the number of falls that the client has had in recent weeks.

1 Clients with cholinergic crisis have experienced overdosage of medication. Edrophonium will exacerbate symptoms in cholinergic crisis to the point at which the client may need intubation and mechanical ventilation. Intravenous atropine sulfate is used to reverse the effects of these anticholinesterase medications. Morphine sulfate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Protamine sulfate is the antidote for heparin.

A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The health care provider plans to administer edrophonium to differentiate between myasthenic and cholinergic crises. The nurse ensures that which medication is available in the event that the client is in cholinergic crisis? 1.Atropine sulfate 2.Morphine sulfate 3.Protamine sulfate 4.Pyridostigmine bromide

2 Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last from seconds to minutes. The pain often is described as either stabbing or similar to an electric shock. It is accompanied by spasms of the facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. It is treated by giving antiseizure medications, such as gabapentin, and sometimes tricyclic antidepressants. These medications work by stabilizing the neuronal membrane and blocking the nerve.

The nurse is providing discharge education to a client diagnosed with trigeminal neuralgia. Which medication will likely be prescribed upon discharge for this condition? 1.Lorazepam 2.Gabapentin 3.Carisoprodol 4.Chlordiazepoxide

1 The pain that accompanies trigeminal neuralgia is triggered by stimulation of the trigeminal nerve. Symptoms can be triggered by pressure such as from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by stimulation by a draft or cold air. The remaining options are not associated with triggering episodes of pain.

The nurse is providing instructions to the client with trigeminal neuralgia regarding measures to take to prevent the episodes of pain. Which should the nurse instruct the client to do? 1.Prevent stressful situations. 2.Avoid activities that may cause fatigue. 3.Avoid contact with people with an infection. 4.Avoid activities that may cause pressure near the face.

3 Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.

The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder? 1."Do your eyes feel dry?" 2."Do you have any spasms in your throat?" 3."Are you having any difficulty chewing food?" 4."Do you have any tingling sensations around your mouth?

4 Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye. The remaining options do not elicit data specifically related to this disorder.

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder? 1."Do you have any visual problems?" 2."Are you having any problems hearing?" 3."Do you have any tingling in the face region?" 4."Is the pain experienced a stabbing type of pain?"

4 to manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate a bowel movement on an every-other-day basis and should sit on the toilet or commode. This should be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action? 1.Drinking a total of 1000 mL/day 2.Giving herself an enema every morning before breakfast 3.Taking stool softeners daily and a glycerin suppository once a week 4.Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

3 Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency, frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia. The questions in the remaining options are unrelated to the use of this medication.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin. The nurse evaluates the effectiveness of the medication by asking the client which assessment question? 1."Are you consistently fatigued?" 2."Are you having muscle spasms?" 3."Are you getting up at night to urinate?" 4."Are you having normal bowel movements?"

4 Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If brushing the teeth triggers pain, an oral rinse after meals may be helpful instead.

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? 1."I will wash my face with cotton pads." 2."I'll have to start chewing on my unaffected side." 3."I should rinse my mouth if toothbrushing is painful." 4."I'll try to eat my food either very warm or very cold."

2 Exposure to cold or drafts is avoided in Bell's palsy because it can cause discomfort. Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical nerve stimulation. Local application of heat to the face may improve blood flow and provide comfort.

The nurse has given the client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs further teaching if the client makes which statements? 1."I will perform facial exercises." 2."I will expose my face to cold to decrease the pain." 3."I will massage my face with a gentle upward motion." 4."I will wrinkle my forehead, blow out my cheeks, and whistle frequently."

3 Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement? 1."Here's the MedicAlert bracelet I obtained." 2."I should take my medications an hour before mealtime." 3."Going to the beach will be a nice, relaxing form of activity." 4."I've made arrangements to get a portable resuscitation bag and home suction equipment."

2 The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruits and vegetables is a healthy and an unrelated item.

A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, should the nurse identify as being unrelated to the exacerbation? 1.Annual influenza vaccination 2.Ingestion of increased fruits and vegetables 3.An established routine of walking 2 miles each evening 4.A recent period of extreme outside ambient temperatures

2 The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia.

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom? 1.A symmetrical smile 2.Difficulty closing the eyelid on the affected side 3.Narrowing of the palpebral fissure on the affected side 4.Paroxysms of excruciating pain in the lips and cheek on the affected side

3 Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1.Getting too little exercise 2.Taking excess medication 3.Omitting doses of medication 4.Increasing intake of fatty food

3 A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. A Foley catheter should be used only when necessary because of the associated risk of infection. Use of diapers or pads is the least acceptable alternative because of the risk of skin breakdown.

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? 1.Using adult diapers 2.Inserting a Foley catheter 3.Establishing a toileting schedule 4.Padding the bed with an absorbent cotton pad

3 Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelination of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait. The remaining options are not related to the data in the question.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care? 1.Inability to care for self 2.Interruption in skin integrity 3.Interruption in physical mobility 4.Inability to perform daily activities

2 The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which most important items available at the client's bedside? 1.Oxygen and metered-dose inhaler 2.Ambu bag and suction equipment 3.Pulse oximeter and cardiac monitor 4.Incentive spirometer and cough pillow

1 Clients with Bell's palsy should be reassured that they have not experienced stroke a (brain attack) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bell's palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches.

A client with recent-onset Bell's palsy is upset and crying about the change in facial appearance. The nurse plans to support the client emotionally by making which statement to the client? 1."This is not a stroke, and many clients recover in 3 to 5 weeks." 2."This is caused by a small tumor, which can be removed easily." 3."This is similar to a stroke, but all symptoms will reverse without treatment." 4."This is a temporary problem, with treatment similar to that for migraine headaches."

3 The client with myasthenia gravis and the family should be taught information about the disease and its treatment. They should be aware of the side and adverse effects of anticholinesterase medications and corticosteroids and should be taught that timing of anticholinesterase medication is critical. It is important to instruct the client to administer the medication on time to maintain a chemical balance at the neuromuscular junction. If it is not given on time, the client may become too weak to even swallow. Resting after a walk, coughing and deep-breathing many times during the day, and calling the health care provider when experiencing abdominal cramps and diarrhea indicate a correct understanding of home care instructions to maintain health with this neurological degenerative disease.

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further teaching? 1."I will rest each afternoon after my walk." 2."I should cough and deep breathe many times during the day." 3."I can change the time of my medication on the mornings when I feel strong." 4."If I get abdominal cramps and diarrhea, I should call my health care provider."

2 Impairment of cranial nerve XII can occur with a stroke. To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse would assess the client's ability to extend the tongue. The maneuvers noted in the remaining options do not test the function of cranial nerve XII.

The nurse is assessing the function of cranial nerve XII in a client who sustained a stroke. To assess function of this nerve, which action should the nurse ask the client to perform? 1.Extend the arms. 2.Extend the tongue. 3.Turn the head toward the nurse's arm. 4.Focus the eyes on the object held by the nurse.

3 The parkinsonian gait is characterized by short, accelerating, shuffling steps. The client leans forward with the head, hips, and knees flexed and has difficulty starting and stopping. An ataxic gait is unsteady and staggering. A dystrophic gait is broad-based and waddling. Walking on the toes can occur from shortened Achilles tendons.

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client? 1.Walking on the toes 2.Unsteady and staggering 3.Shuffling and propulsive 4.Broad-based and waddling

4 Because mild tactile stimulation of the face can trigger pain in trigeminal neuralgia, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal nerve pain. Therefore, the options that include cocoa, hot herbal tea, and iced coffee are incorrect.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The client asks for a snack and something to drink. The nurse should offer which best snack to the client? 1.Cocoa with honey and toast 2.Hot herbal tea with graham crackers 3.Iced coffee and peanut butter and crackers 4.Vanilla wafers and room-temperature wa

4 The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1."I can sit down to put on my pants and shoes." 2."I try to exercise every day and rest when I'm tired." 3."My son removed all loose rugs from my bedroom." 4."I don't need to use my walker to get to the bathroom.

1 Bell's palsy is a one-sided facial paralysis caused by the compression of the facial nerve (cranial nerve VII). Assessment findings include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulty. The remaining options are not associated findings in Bell's palsy.

The nurse is performing an assessment on a client with a diagnosis of Bell's palsy. The nurse should expect to observe which finding in the client? 1.Facial drooping 2.Periorbital edema 3.Ptosis of the eyelid 4.Twitching on the affected side of the face

4 Spacing fluid intake over the day helps the client with a neurogenic bladder to establish regular times for successful voiding. Omitting intake after the evening meal minimizes incontinence or the need to empty the bladder during the night.

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 1.400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 2.400 to 500 mL with each meal and additional fluids in the morning but not after midday 3.400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening 4.400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

1234 A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. 1.Provide oral hygiene after each meal. 2.Assess swallowing ability frequently. 3.Allow the client sufficient time to eat. 4.Maintain a suction machine at the bedside. 5.Provide a full liquid diet for ease in swallowing.

4 Dietary changes, such as salt and fluid restrictions, that reduce the amount of endolymphatic fluid are sometimes prescribed for the client with Ménière's disease. The client should be instructed to consume a low-sodium diet and restrict fluids as prescribed. Although helpful to treat other disorders, low-fat, low-carbohydrate, and low-cholesterol diets are not specifically prescribed for the client with Ménière's disease.

The nurse is providing diet instructions to a client with Ménière's disease who is being discharged from the hospital after admission for an acute attack. Which statement, if made by the client, indicates an understanding of the dietary measures to take to help prevent further attacks? 1."I need to restrict my carbohydrate intake." 2."I need to drink at least 3 L of fluid per day." 3."I need to maintain a low-fat and low-cholesterol diet." 4."I need to be sure to consume foods that are low in sodium."

2 The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1.Muscle wasting 2.Mild clumsiness 3.Altered mentation 4.Diminished gag reflex

1) lients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1.Taking medications as scheduled 2.Eating large, well-balanced meals 3.Doing muscle-strengthening exercises 4.Doing all chores early in the day while less fatigued

4 The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, or drinking. Symptoms also can be triggered by thermal stimuli, such as a draft of cold air. The remaining options are incorrect.

the nurse is caring for a client diagnosed with trigeminal neuralgia. The client asks the nurse, "Why do I have so much pain?" Which is the appropriate response by the nurse? 1."It's a local reaction to nasal stuffiness." 2."It's due to a hypoglycemic effect on the cranial nerve." 3."Release of catecholamines with infection or stress leads to the pain." 4."Pain is due to stimulation of the affected nerve by pressure and temperature."