Test 3 Neurologic Dysfunction #2 - From Mom
Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation? A. Hemorrhagic skin rash B. Edema C. Cyanosis D. Dyspnea on exertion
Correct Answer: A. Hemorrhagic skin rash DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition. Disseminated intravascular coagulation (DIC) can be defined as a widespread hypercoagulable state that can lead to both microvascular and macrovascular clotting and compromised blood flow, ultimately resulting in multiple organ dysfunction syndrome or MODS. As this process begins consuming clotting factors and platelets in a positive feedback loop, hemorrhage can ensue, which may be the presenting symptom of a patient with DIC. Option B: Increased intracranial pressure from cerebral edema caused by increased intracellular fluid in the brain. Several factors are involved in the development of cerebral edema: increased blood-brain barrier permeability, cytotoxicity from cytokines, immune cells, and bacteria. Option C: Cyanosis, broadly speaking, is caused by disorders of deoxygenated hemoglobin and disorders of abnormal hemoglobin. Oxygen might not reach hemoglobin in an adequate or sufficient amount as a result of conditions affecting the respiratory system, cardiovascular system, and the central nervous system. Option D: Dyspnea on exertion is a symptom of various diseases rather than a disease itself. As such, its etiology can be designated as arising from two primary organ systems: the respiratory system and the cardiac system. Other systemic illnesses may be the culprit as well as a combination of different etiologies.
When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report: A. Light flashes and floaters in front of the eye. B. A recent driving accident while changing lanes. C. Headaches, nausea, and redness of the eyes. D. Frequent episodes of double vision.
Correct Answer: A. Light flashes and floaters in front of the eye. The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Patients with a rhegmatogenous retinal detachment may present with a history of a large number of new-onset floaters. They may also have significant photopsia (flashes of light) in their vision. Option B: Difficulty seeing cars in another driving lane suggests a gradual loss of peripheral vision, which may indicate glaucoma. Many patients with glaucoma, especially early in the disease, are not aware they have this condition until it is discovered on a routine eye exam. People generally slowly lose peripheral vision but retain central vision until the disease process is severe. Option C: Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. In the acute angle-closure type, patients typically present with severe sudden ocular pain, redness, blurry vision/decreased visual acuity, headache, nausea or vomiting, and may complain of seeing halos of light. Patients will have an unresponsive mid-dilated pupil on examination and a firm feeling eyeball on palpation. Option D: Double vision is common in clients with cataracts. Diplopia or polyopia, mostly uniocular but can be binocular, is due to multiple refractions through clear areas between the opacities. A cataract is a clouding or opacification of the normally clear lens of the eye or its capsule (surrounding transparent membrane) that obscures the passage of light through the lens to the retina of the eye.
Which of the following assessment data indicated nuchal rigidity? A. Positive Kernig's sign B. Negative Brudzinski's sign C. Positive homan's sign D. Negative Kernig's sign
Correct Answer: A. Positive Kernig's sign A positive Kernig's sign indicated nuchal rigidity, caused by an irritative lesion of the subarachnoid space. Brudzinski's sign is also indicative of the condition. To elicit the Kernig sign, clinicians typically perform the exam with the patient lying supine with the thighs flexed on the abdomen, and the knees flexed. The examiner then passively extends the legs. In the presence of meningeal inflammation, the patient will resist leg extension or describe pain in the lower back or posterior thighs, which indicates a positive sign. Option B: Brudzinski's sign is characterized by reflexive flexion of the knees and hips following passive neck flexion. To elicit this sign, the examiner places one hand on the patient's chest and the other hand behind the patient's neck. The examiner then passively flexes the neck forward and assesses whether the knees and hips flex. Upon passive neck flexion, a positive test results when the patient flexes his knees and hips. Option C: Homan's sign test also called dorsiflexion sign test is a physical examination procedure that is used to test for deep vein thrombosis (DVT). A positive Homan's sign in the presence of other clinical signs may be a quick indicator of DVT. Clinical evaluation alone cannot be relied on for patient management, but when carefully performed, it remains useful in determining the need for additional testing (like D-dimer test, ultrasonography, multidetector helical computed axial tomography (CT), and pulmonary angiography) Option D: When the meninges in the spinal cord and spinal nerves are inflamed, patients will resist stretching the cord and the nerves to prevent pain resulting from this inflammation. These clinical maneuvers appear to provoke this stretching.; this is why contractures occur when performed, resulting in a positive test.
The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply. A. Increased appetite B. Vomiting C. Polydipsia D. Lethargy E. Head tilt F. Increased pulse
Correct Answer: B, D & E Head tilt, vomiting, and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor. Tumors that develop in the brain are called primary tumors. Tumors that spread to the brain after forming in a different part of the body are called secondary tumors or metastatic tumors. This article focuses on primary tumors. There are more than 100 types of primary brain and spinal cord tumors. Option A: Increased appetite is not a sign of brain tumor. Seizures are the second most common symptom of presentation. The pathophysiology of seizures is attributed to tumor irritation to the cerebral cortex that leads to focal or generalized seizures. Other presenting symptoms of gliomas are tingling sensations, weakness, difficulty ambulation, and in rare cases, patients can present in a comatose state due to hemorrhage within the tumor which leads to an acute herniation syndrome. Option B: The most common presentations in brain gliomas are headaches, nausea, vomiting, seizures, and in more advanced cases weakness or altered mental status. Other symptoms related to mass effects include nausea, vomiting, and change in vision. Option C: Polydipsia is not found in a patient with a brain tumor. Symptoms that may be specific to the location of the tumor include changes in judgment, including loss of initiative, sluggishness, and muscle weakness or paralysis is associated with a tumor in the frontal lobe of the cerebrum; or changes in speech, hearing, memory, or emotional state, such as aggressiveness and problems understanding or retrieving words can develop from a tumor in the frontal and temporal lobe of the cerebrum. Option D: The neurological examination of these patients can be normal or present with different degrees of focal weakness, sensory deficits, or in a severe situation altered mental status due to an acute mass effect resulting from the tumor swelling. Option E: Headaches are the most common initial presenting symptom of patients with glioma. The pathophysiology of headaches is theorized to be the result of tumor growth that places a mass effect on surrounding tissue. The mass effect, in turn, leads to pressure in the microvasculature and leads to edema. Depending on the location of the tumor in the brain, the mass effect leads to signs of a brain tumor. Option F: Meningiomas present with typical brain tumor symptoms such as headaches, vision problems, or seizures. A headache-even a severe one-on its own is seldom a symptom of meningioma or any other brain tumor.
A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. A. Is disoriented to person, place, and time. B. Affect is flat, with periods of emotional lability. C. Cannot recall what was eaten for breakfast today. D. Demonstrate inability to add and subtract; does not know who is the president.
Correct Answer: B. Affect is flat, with periods of emotional lability. The limbic system is responsible for feelings (affect) and emotions. While the limbic system was initially suggested to be the sole neurological system involved in regulating emotion, it is now considered only one part of the brain to regulate visceral, autonomic processes. In general, the limbic system assists in various processes relating to cognition; including spatial memory, learning, motivation, emotional processing, and social processing. Option A: The cerebral hemispheres, with specific regional functions, control orientation. The frontal lobe further divides into a superior, middle, and inferior frontal gyrus, primary motor cortex, and orbital area. These areas combine to control our executive and motor functions. It controls judgment, problem-solving, planning, behavior, personality, speech, writing, speaking, concentration, self-awareness, and intelligence. The parietal lobe is posterior to the central sulcus and anterior to the parieto-occipital sulcus. This lobe controls perception and sensation. The occipital lobe is posterior to the parieto-occipital sulcus and superior to the tentorium cerebelli. This lobe interprets vision, distance, depth, color, and facial recognition. The temporal lobe is inferior to the lateral fissure and further divides into a superior, middle, and inferior temporal gyrus. This lobe controls language comprehension, hearing, and memory. Option C: Recall of recent events is controlled by the hippocampus. The hippocampus, parahippocampal region of the medial temporal lobe, and the neocortical association have been shown through the autopsy and imaging studies to be essential for memory processing. Impairment of short-term memory leading up to an inability to form new memories occurs when there is bilateral damage to the above-mentioned regions. Option D: Calculation ability and knowledge of current events relates to the function of the frontal lobe. The frontal lobe further divides into a superior, middle, and inferior frontal gyrus, primary motor cortex, and orbital area. These areas combine to control our executive and motor functions. It controls judgment, problem-solving, planning, behavior, personality, speech, writing, speaking, concentration, self-awareness, and intelligence.
Which of the following pathologic processes is often associated with aseptic meningitis? A. Ischemic infarction of cerebral tissue. B. Childhood diseases of viral causation such as mumps. C. Brain abscesses caused by a variety of pyogenic organisms. D. Cerebral ventricular irritation from a traumatic brain injury.
Correct Answer: B. Childhood diseases of viral causation such as mumps. Aseptic meningitis is caused principally by viruses and is often associated with other diseases such as measles, mumps, herpes, and leukemia. Aseptic meningitis is a term used to define inflammation of the brain meninges due to various etiologies with negative cerebrospinal fluid (CSF) bacterial cultures. It is one of the most common, usually benign, inflammatory disorders of the meninges. Viruses are a common etiology, however, there are many other infective and non-infective causes. Therefore, the terms aseptic meningitis and viral meningitis are not interchangeable. Option A: Ischemic infarction of cerebral tissue can occur with tubercular meningitis. In tuberculous meningitis, the meninges are seeded by MTB and form sub-ependymal collections called Rich foci. These foci can rupture into the subarachnoid space and cause an intense inflammatory response that causes the symptoms of meningitis. Option C: Incidences of brain abscess are high in bacterial meningitis. Several possible risk factors for bacterial meningitis have been identified. Patients with an abnormal communication between the nasopharynx and subarachnoid space are thought to be at increased risk. This abnormal communication can be due to a congenital abnormality or a result of trauma. Patients who have undergone neurosurgery, sustained skull fractures, or have cochlear implants are also at increased risk. Option D: Traumatic brain injury could lead to bacterial (not viral) meningitis. Nosocomial bacterial meningitis is the result of the manipulation of the meninges during neurosurgical procedures. Invasion of bacteria into the subarachnoid space results in inflammation of the meninges.
A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis? A. Cloudy CSF, decreased protein, and decreased glucose. B. Cloudy CSF, elevated protein, and decreased glucose. C. Clear CSF, elevated protein, and decreased glucose. D. Clear CSF, decreased pressure, and elevated protein.
Correct Answer: B. Cloudy CSF, elevated protein, and decreased glucose. A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy CSF, elevated leukocytes, elevated protein, and decreased glucose levels. Option A: Patients presumed to have bacterial meningitis should receive a lumbar puncture to obtain a cerebrospinal fluid (CSF) sample. The CSF should be sent for Gram stain, culture, complete cell count (CBC), and glucose and protein levels. Bacterial meningitis typically results in low glucose and high protein levels in the cerebrospinal fluid. Option C: As CSF glucose levels are dependent on circulating serum glucose levels, the CSF to serum glucose ratio is considered a more reliable parameter for the diagnosis of acute bacterial meningitis than absolute CSF glucose levels. A neutrophil predominance on cell count would be expected. Option D: A clear CSF is normal. Symptoms are similar to aseptic meningitis, but clinical presentation is much more severe. Additional symptoms include altered mental status, seizures, and focal neurologic signs. Diagnosis is also possible via LP. CSF is usually cloudy in appearance, with a low glucose level, and potential positive gram stain and culture. Patients presumed to have bacterial meningitis should immediately receive broad-spectrum antibiotics to prevent clinical deterioration.
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis? A. Imbalanced nutrition: Less than body requirements B. Ineffective airway clearance C. Impaired urinary elimination D. Risk for injury
Correct Answer: B. Ineffective airway clearance In Parkinson's crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren't immediately life-threatening. Option A: Assess the patient's ability to eat. To provide information regarding factors associated with reduced intake of nutrients. Weigh the patient daily, on the same scale and same time if possible. Provides information about weight loss or gain. Provide an unhurried environment during meal time. Patients with PD may have difficulty maintaining their weight as eating becomes a very slow process, requiring concentration due to a dry mouth from medications and difficulty chewing and swallowing. Option C: Teach patient to sit in chairs with backs and armrests; use elevated toilet seats or sidebars in the bathroom. Help with rising from a sitting position and prevent falls. Provide warm baths and massages. Helps relax muscles and relieve painful muscle spasms that accompany rigidity. Option D: Assess ambulation and movement. Instruct the patient to swing arms and lift heels during ambulation. These actions assist gait and prevent falls. Teach the patient to turn in wide arcs. To prevent the crossing of one leg over the other, which could cause a fall. Remind the patient to maintain an upright posture and look up when walking. Stooped posture may cause the patient to collide with objects.
Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions? A. Congenital anatomic abnormality of the meninges. B. Lack of acquired resistance to the various etiologic organisms. C. Occlusion or narrowing of the CSF pathway. D. Natural affinity of the CNS to certain pathogens.
Correct Answer: B. Lack of acquired resistance to the various etiologic organisms. Extension of a variety of bacterial infections is a major causative factor of meningitis and occurs as a result of a lack of acquired resistance to the etiologic organisms. Preexisting CNS anomalies are factors that contribute to susceptibility. Meningitis can be caused by infectious and non-infectious processes (autoimmune disorders, cancer/paraneoplastic syndromes, drug reactions). The infectious etiologic agents of meningitis include bacteria, viruses, fungi, and less commonly parasites. Option A: The most common viral agents of meningitis are non-polio enteroviruses (group b coxsackievirus and echovirus). Other viral causes: mumps, Parechovirus, Herpesviruses (including Epstein Barr virus, Herpes simplex virus, and Varicella-zoster virus), measles, influenza, and arboviruses (West Nile, La Crosse, Powassan, Jamestown Canyon). Option C: Organisms can enter the cerebrospinal fluid (CSF) via neighboring anatomic structures (otitis media, sinusitis), foreign objects (medical devices, penetrating trauma), or during operative procedures. Viruses can penetrate the central nervous system (CNS) via retrograde transmission along neuronal pathways or by hematogenous seeding. Option D: Bacteria colonize the nasopharynx and enter the bloodstream after mucosal invasion. Upon making their way to the subarachnoid space, the bacteria cross the blood-brain barrier, causing a direct inflammatory and immune-mediated reaction.
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis? A. Bladder infection B. Middle ear infection C. Fractured clavicle D. Septic arthritis
Correct Answer: B. Middle ear infection Organisms that cause bacterial meningitis, such as pneumococci or meningococci, are commonly spread in the body by vascular dissemination from a middle ear infection. Meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found. Option A: Bladder infection does not cause meningitis. The most common bacterial culprit varies by age. Group B Streptococcus is common in infants less than 2 months of age while Streptococcus pneumoniae is the most common in all other age groups, with the exception of 11 - 17 year olds, where Neisseria meningitidis is still the most common cause. Option C: A fractured clavicle does not lead to meningitis. History should include questioning about any recent neurosurgical procedures, immunization status, and living arrangements. A physical exam may reveal nuchal rigidity or positive Kernig's or Brudzinski's signs. Option D: Septic arthritis rarely leads to bacterial meningitis. Nosocomial infections are caused by S. pneumonia, Staphylococcus aureus, Staphylococcus albus, and gram-negative bacilli. As per Thigpen etal. out of the 1670 cases reported in the U.S. during 2003-2007, S. pneumoniae was the predominant infective species (58.0%), followed by GBS (18.1%), N. meningitidis (13.9%), H. influenzae (6.7%), and L. monocytogenes (3.4%).
A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present? A. Abnormal flexion of the upper extremities and extension of the lower extremities. B. Rigid extension and pronation of the arms and legs. C. Rigid pronation of all extremities. D. Flaccid paralysis of all extremities.
Correct Answer: B. Rigid extension and pronation of the arms and legs. Decerebrate posturing is characterized by the rigid extension and pronation of the arms and legs. Synonymous terms for decerebrate posturing include abnormal extension, decerebrate rigidity, extensor posturing, or decerebrate response. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons. Option A: Synonymous terms for decorticate posturing include abnormal flexion, decorticate rigidity, flexor posturing, or decorticate response. The mechanism for decorticate posturing is not as well studied as that of decerebrate. Phylogenetically, the region of the red nucleus within the midbrain plays a significant part in locomotion. In primates, the rubrospinal tract influences primitive grasp reflexes, particularly in infants, and is, incidentally, responsible for crawling. Option C: Pronation is a natural movement of the foot that occurs during foot landing while running or walking. Composed of three cardinal plane components: subtalar eversion, ankle dorsiflexion, and forefoot abduction. These three distinct motions of the foot occur simultaneously during the pronation phase. Option D: Flaccid paralysis is a neurological condition characterized by weakness or paralysis and reduced muscle tone without other obvious cause (e.g., trauma). This abnormal condition may be caused by disease or by trauma affecting the nerves associated with the involved muscles.
A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? A. No precautions are required as long as antibiotics have been started. B. Maintain enteric precautions. C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. D. Maintain neutropenic precautions.
Correct Answer: C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Antibiotics are given to treat the underlying causes of inflammation and thus prevent the occurrence of seizure activity. Option A: Assess neurologic status to include VS pattern, changes in consciousness, behavior patterns and pupillary/ocular responses appropriate for age (measure head circumference in infant) (specify when). Administer antibiotics as prescribed (specify) as soon as ordered based on analysis of CSF, throat cultures. Option B: Enteric precautions are taken to prevent infections that are transmitted primarily by direct or indirect contact with fecal material. They're indicated for patients with known or suspected infectious diarrhea or gastroenteritis. Clostridium difficile is the most common cause of hospital-acquired infectious diarrhea. Option D: Neutropenic precautions are steps one can take to prevent infections if they have moderate to severe neutropenia. Neutropenia is a condition that causes the client to have low neutrophils in the blood. Neutrophils are a type of white blood cell that helps the body fight infection and bacteria. Ask a healthcare provider for more information on neutropenia.
After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client? A. Give him a barbiturate. B. Place him on mechanical ventilation. C. Perform a lumbar puncture. D. Elevate the head of his bed.
Correct Answer: C. Perform a lumbar puncture. The client's history and assessment suggest that he may have increased intracranial pressure (ICP). If this is the case, lumbar puncture shouldn't be done because it can quickly decompress the central nervous system and, thereby, cause additional damage. A head computed tomogram (CT) should be obtained before performing a lumbar puncture if there is a concern for increased intracranial pressure. Signs and symptoms of possible increased intracranial pressure include altered mental status, focal neurological deficits, new-onset seizure, papilledema, immunocompromised state, malignancy, history of focal CNS disease (stroke, focal infection, tumor), concern for mass CNS lesion and age greater than 60 years old. Option A: After a head injury, barbiturates may be given to prevent seizures. Phenobarbital has extensive use as an antiepileptic drug in the neonatal and pediatric population. It is the most cost-effective drug treatment for epilepsy in adults in low resource countries. Intravenous barbiturates have been used for neurosurgery due to the reduction in cerebral metabolic rate of oxygen consumption. Option B: Mechanical ventilation may be required if breathing deteriorates. The clinical presentation of increased intracranial pressure can easily be mistaken for other issues, such as intoxication, stroke, infection, or postictal state. It requires a high index of suspicion, particularly in milder cases. In more severe cases, close neurological monitoring and consultation with neurology and neurosurgery are important. Option D: Elevating the head of the bed may be used to reduce ICP. Elevate the head of the bed to greater than 30 degrees. Keep the neck midline to facilitate venous drainage from the head. Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure.
A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors. B. Providing positive feedback and encouraging active range of motion. C. Providing information, giving positive feedback and encouraging relaxation. D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.
Correct Answer: C. Providing information, giving positive feedback, and encouraging relaxation. The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well. Option A: Allow the client to participate in their own care depending on ability and degree of paralysis; allow them to make informed choices about ADL as soon as possible. Promotes independence and control and preserves developmental status. Option B: Teach parents and the client about disease condition and manifestation. Provides information to relieve anxiety by knowledge of what to expect. Discuss each procedure or type of may therapy, effects of any diagnostic tests to parents and client as appropriate to age. Reduces fear of the unknown which increases anxiety. Option D: Therapeutically communicate with parents and child and answer questions in a calm and honest manner. Promotes an environment of support. Facilitate expression of concerns and an opportunity to ask inquiries regarding the condition and rehabilitation of the ailing child. Provides an opportunity to release feelings, secure information needed to overcome anxiety.
A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client's blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take? A. Loosen tight clothing or accessories B. Assess for any bladder distention C. Raise the head of the bed D. Administer antihypertensive
Correct Answer: C. Raise the head of the bed The client is experiencing an autonomic dysreflexia, a life-threatening medical emergency that affects individuals with spinal injuries. Usually an individual with SCI has a blood pressure reading of 20 mm to 40 mm Hg above baseline. If this condition is suspected, the priority nursing action is to raise the head of bed or place the client in high Fowler's position. This promotes adequate ventilation and prevents the occurrence of hypertensive stroke. Options A & B: After positioning the client in high Fowler's position, the nurse should remove any noxious stimuli that may trigger autonomic dysreflexia by loosening any tight clothing or objects that might be tight-fitting such as a bracelet, shoes, or stockings and check the bladder if it is too full. Option D: Antihypertensive medication may be prescribed such as nifedipine and nitrates to decrease cerebral hypertension.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN? A. Complete admission assessment. B. Place a padded tongue blade at the bedside. C. Set up oxygen and suction equipment. D. Pad the side rails before the patient arrives.
Correct Answer: C. Set up oxygen and suction equipment. The LPN/LVN can set up the equipment for oxygen and suctioning. Supportive care with attention to airway, breathing, and circulation issues are vital. Clear communication between team members is essential since patients' clinical status may abruptly change. Most patients will have a single, brief, uncomplicated event and return to full consciousness. Detection of any underlying cause of the seizure or seizures is important, so that appropriate therapy or counseling is available. Option A: The RN should perform the complete initial assessment. There are many causes of seizures, but regardless of the cause, the basic initial treatment is similar. Seizure patients all require supportive care and assessment of airway, breathing, and circulation with appropriate interventions. Option B: Tongue blades should not be at the bedside and should never be inserted into the patient's mouth after a seizure begins. For patients with a prolonged seizure or continuing seizures, other interventions, including medications and critical care interventions, may be necessary. Communication and coordination with other health care providers are essential to optimize team response. Option D: Padded side rails are controversial in terms of whether they actually provide safety and may embarrass the patient and family. Most generalized seizures terminate in less than five minutes and a seizure of longer duration or serial seizures without regaining full consciousness in between defines status epilepticus. Whether status epilepticus is from provoked causes or unprovoked causes, initial treatment is similar.
A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning? A. phenytoin (Dilantin) B. mannitol (Osmitrol) C. lidocaine (Xylocaine) D. furosemide (Lasix)
Correct Answer: C. lidocaine (Xylocaine) Administering lidocaine via an endotracheal tube may minimize elevations in ICP caused by suctioning. Lidocaine use, both intravenous (IV) and laryngotracheal (LT), has been reported to blunt the ICP elevations during intubation. Though one would assume that the ICP mediated effects of lidocaine stem from its local anesthetic effect, there are other proposed mechanisms of ICP reduction via the IV route. Lidocaine injected IV has been shown in models to induce cerebral vasoconstriction leading to a decrease in cerebral blood volume and thus ICP. Furthermore, IV lidocaine leads to sodium channel inhibition and thus a reduction in cerebral activity and metabolic demands, as well as excitotoxicity, leading to a potential ICP reduction effect. Option A: Phenytoin doesn't reduce ICP directly but may be used to abolish seizures, which can increase ICP. However, phenytoin isn't administered endotracheally. Phenytoin is a hydantoin derivative, a first-generation anticonvulsant drug that is effective in the treatment of generalized tonic-clonic seizures, complex partial seizures, and status epilepticus without significantly impairing neurological function. Option B: Mannitol may be used for the reduction of intracranial pressure. In this indication, mannitol administration is intravenous. Mannitol then constitutes a new solute in the plasma, which increases the tonicity of the plasma. Since mannitol cannot cross the intact blood-brain barrier, the increased tonicity from the mannitol draws water out of the brain parenchyma and into the intravascular space. The water then travels with the mannitol to the kidneys, where it gets excreted in the urine. Option D: Although furosemide may be given to reduce ICP, they're administered parenterally, not endotracheally. Furosemide inhibits tubular reabsorption of sodium and chloride in the proximal and distal tubules, as well as in the thick ascending loop of Henle by inhibiting sodium-chloride cotransport system resulting in excessive excretion of water along with sodium, chloride, magnesium, and calcium.
The nurse has given the male client with Bell's palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will: A. Wrinkle the forehead, blow out the cheeks, and whistle. B. Massage the face with a gentle upward motion. C. Perform facial exercises. D. Exposure to cold and drafts.
Correct Answer: D. Exposure to cold and drafts. Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort. Facial pain is controlled with analgesic agents or heat applied to the involved side of the face. Option A: The neurology nurse must educate the patient on facial exercises that can help improve muscle strength and facial coordination. These exercises can reduce poor aesthetics and improve the functionality of the facial muscles. Option B: Show the patient how to perform facial massage with gentle upward motion several times daily when the patient can tolerate the massage. Massage and mild electrical stimulation of the paralyzed muscles can help maintain facial muscle tone and prevent the loss of muscle function. Option C: Prevention of muscle atrophy with Bell's palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves. Demonstrate facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy.
A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions? A. Visual neglect B. Astigmatism C. Blepharitis D. Homonymous Hemianopsia
Correct Answer: D. Homonymous Hemianopsia Homonymous Hemianopsia is the loss of half of the visual field. It is usually caused by a stroke, brain tumor, and trauma. A client with hemianopia may bump into things on the side of the visual field defect and often lose their place in reading due to the visual field loss. Option A: Visual neglect is an attention problem to one side of the body. It is a sensory loss limited to the visual fields and results from damage to the primary visual pathways connecting the optic tract and striate cortex. Option B: Astigmatism is a condition that causes blurred vision due either to the irregular shape of the cornea, the clear front cover of the eye, or sometimes the curvature of the lens inside the eye. Option C: Blepharitis is the inflammation of the eyelids that is usually caused by a bacterial infection of the eyelid margin at the origin of the eyelashes. Signs and symptoms include itching and burning of the eyelid margins with edema and redness.
A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information would you expect to find in this client? A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks. B. It is a non-progressive neurological disorder of the seventh cranial nerve causing paralysis of one of the sides of the face. C. It is a rare degenerative brain disorder characterized by sudden development of progressive neurological and neuromuscular symptoms. D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth.
Correct Answer: D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth. Sturge-Weber syndrome, also known as encephalofacial or encephalotrigeminal angiomatosis, is a neurocutaneous syndrome that is associated with a port-wine birthmark (facial port-wine stains in the trigeminal nerve distribution), vascular lesions in the ipsilateral brain and meninges, and eye problems such as glaucoma. Option A: It is a description of a client with Trigeminal neuralgia. Option B: It is a description of a client with a Bell's Palsy. Option C: It is a description of a client with Creutzfeldt-Jakob disease (CJD).
A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety? A. Speak loudly to the client. B. Test the temperature of the shower water. C. Check the temperature of the food on the delivery tray. D. Provide a clear path for ambulation without obstacles.
Correct Answer: D. Provide a clear path for ambulation without obstacles. Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating. Compromise of the optic nerve results in visual field defects and/or visual loss. The type of visual field defect depends on which region of the optic pathway is disrupted. Option A: Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). CN VIII injuries are the result of pathological processes or injuries that commonly involve the cerebellopontine angle (CPA), the internal auditory canal (IAC), or the inner ear. In such cases, symptoms such as vertigo, nystagmus, tinnitus, and sensorineural hearing loss may occur. Option B: Testing the shower water temperature would be useful if there were an impairment of peripheral nerves. Peripheral nerve injury can cause sensory deficits, loss of motor function, or a combination of both. Recovery from peripheral nerve injury is often incomplete and patients may experience chronic pain. Option C: Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two-thirds and posterior third of the tongue, respectively. The facial nerve provides motor innervation of facial muscles that are responsible for facial expression, parasympathetic innervation of the glands of the oral cavity and the lacrimal gland, and sensory innervation of the anterior two-thirds of the tongue.
A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of: A. Seizures or trauma to the brain. B. Meningitis during the last five (5 years). C. Back injury or trauma to the spinal cord. D. Respiratory or gastrointestinal infection during the previous month.
Correct Answer: D. Respiratory or gastrointestinal infection during the previous month. Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery. Option A: Many infections have been linked with GBS. The most common are gastrointestinal or respiratory illnesses. Up to 70% of patients have reported an antecedent illness in the 1 to 6 weeks before the presentation of GBS. During the Zika virus outbreak, many GBS cases were described. Case reports detail many other possible etiologies linked to GBS including medications and surgeries. Option B: The Guillain-Barre syndrome (GBS) and its variants are considered post-infectious, immune-mediated neuropathies. Evidence from animal models suggests a key role of molecular mimicry. In Campylobacter jejuni gastrointestinal infections, a lipooligosaccharide present in the outer membrane of the bacteria is similar to gangliosides that are components of the peripheral nerves. Therefore, an immune response triggered to fight infection can lead to a cross-reaction on host nerves. Option C: In 1976, flu vaccination against the influenza A/H1N1 antigen led to a well-documented, increased incidence of cases of GBS; however, further surveillance data of flu vaccinations in subsequent years have described only one additional case of GBS for every 1 million vaccines. Subsequent studies estimate that developing GBS after a flu infection is up to 7 times more likely than developing GBS after a vaccination.
Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except? A. acetaminophen (Tylenol) B. dexamethasone (Decadron) C. mannitol (Osmitrol) D. phenytoin (Dilantin) E. nitroglycerin (Nitrostat)
Correct Answer: E. nitroglycerin (Nitrostat) Decreasing blood pressure is essential to prevent exacerbation of intracerebral bleeding. However, BP medication such as nitroglycerin is avoided due to its vasodilating effects that increase cerebral blood volume and thus increases intracranial pressure. Option A: Acetaminophen, an antipyretic, prevents increased temperature. A decrease in temperature reduces metabolism, cerebral blood flow, thus decreasing intracranial pressure. It also relieve headache. Option B: Dexamethasone, a corticosteroids, decreases intracranial pressure by stabilizing the cell membrane and decreases the leakiness in the blood-brain-barrier. Option C: Mannitol, an osmotic diuretic, lowers intracranial pressure by increasing intravascular pressure to draw fluid from the interstitial spaces and from the brain cells. Option D: Phenytoin, an anticonvulsant, is given as prophylaxis to prevent seizures. Seizures increase metabolic rate and cerebral blood flow, and volume that may result in increased intracranial pressure.
If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with: A. Body temperature control B. Balance and equilibrium C. Visual acuity D. Thinking and reasoning
Correct Answer: A. Body temperature control The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems of body temperature control. The spinothalamic tract is the sensory pathway for pain, temperature and crude touch that originates in the spinal cord and feeds into the ventral posterolateral nucleus of the thalamus for further processing, while the ventral posteromedial nucleus receives sensory information from the trigeminal nerve about the face. Option B: Balance and equilibrium problems are related to cerebellar damage. Cerebellar dysfunction causes balance problems and gait disorders along with difficulties in coordination resulting in ataxia, uncoordinated movements, imbalance, speech problems(dysarthria), visual problems (nystagmus) and vertigo as a part of the vestibulocerebellar system. Option C: Visual acuity problems would occur following occipital or optic nerve injury. The optic tracts relay sensory information from the contralateral visual fields. For example, the right optic tract relays sensory information from the left visual field. Also, before forming the optic tracts, some nerve fibers from each eye will travel superiorly to synapse in the SCN located within the hypothalamus. This synaptic input influences the circadian rhythm controlled by the SCN. Option D: Thinking and reasoning problems are the result of injury to the cerebrum. Cerebral cortex dysfunction can occur due to a variety of causes (lesions) like tumors, trauma, infections, autoimmune diseases, cerebrovascular accidents. The clinical features for each cause will depend on which lobe is affected. I will review some of the clinical features and their relation to each lobe.
Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL? A. Ataxia B. Potassium deficit C. Neglect syndrome D. Tetraplegia
Correct Answer: A. Ataxia A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 35 mg/dl signifies toxicity. Symptoms of this level of concentration include ataxia, tremor, slurred speech, nausea, and vomiting. Options B, C, & D: Phenytoin does not cause hypokalemia, neglect syndrome (client unaware of the existence of his or her paralyzed side), or tetraplegia (paralysis of all four extremities).
