TTC NUR205: MedSurgII PrepU Chapter 46 (Neuro Disorders)

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

A client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose?

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find?

Vision changes

The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include

sensory disturbance, limb pain, and behavioral changes.

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?

Approximately 60% to 75% of clients recover completely.

The nurse is caring for a client with Parkinson disease (PD). Which finding in the client's medical record will cause the nurse to question giving a prescribed dose of benztropine mesylate?

Narrow-angle glaucoma Benztropine mesylate is an anticholinergic agent that is used to counteract the action of acetylcholine. This medication is contraindicated in clients with narrow-angle glaucoma.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced.

A client is scheduled to receive Gamma Knife therapy. The nurse interprets this as which form of therapy?

Stereotactic radiosurgery Gamma Knife is a form of stereotactic radiosurgery, where precise beams of radiation produce a targeted approach of concentrated radiation for the brain, head, and neck.

A client asks the nurse to explain the development of Parkinson disease (PD). Which response will the nurse provide the client?

"It is caused by low levels of dopamine that are not available to counteract the effects of acetylcholine."

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Cerebellar abscess

Impaired balance and uncontrolled tremors of Parkinson's disease is correlated with which neurotransmitter?

Dopamine

The nurse is caring for a client hospitalized after a motor vehicle accident. The client has a comorbidity of Parkinson's disease. Why should the nurse closely monitor the condition and the drug regimen of a client with Parkinson's disease?

Drugs administered may cause a wide variety of adverse effects.

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

Dyskinesia Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements).

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

When caring for a client with trigeminal neuralgia, which intervention has the highest priority?

Encouraging the client to bathe with care Trigeminal neuralgia is a common disorder that causes severe pain along the trigeminal nerve (the nerve affecting the face) and surrounding areas. The nurse should encourage to the client to be gentle when bathing because performing facial hygiene can cause pain.

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve.

A client is admitted to undergo lumbar laminectomy for treatment of a herniated disk. Which action should the nurse take first to promote comfort preoperatively?

Help the client assume a more comfortable position.

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan?

Keeping the head in a neutral position After a cervical discectomy, the client typically wears a cervical collar. The client should be instructed to keep his head in a neutral position and wear the collar at all times unless the physician has instructed otherwise.

Which is the primary vector of arthropod-borne viral encephalitis in North America?

Mosquitoes The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis

Which diagnostic test is used for early diagnosis of HSV-1 encephalitis?

Polymerase chain reaction (PCR)

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?

Providing supportive care vCJD is a progressive fatal disease, and no treatment is available.

The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?

Ptosis and diplopia The initial manifestation of myasthenia gravis in two-thirds of clients involves the ocular muscles; diplopia and ptosis are common

A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?

Respiratory function Respiratory function is profoundly affected by ALS and would be prioritized over integumentary assessment.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms?

Vasopressin

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

Verapamil (Calan)

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy.

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Ensure atropine is readily available.

A client comes to the clinic reporting low back pain and muscle spasms. He states, "The pain seems to travel into my hip and down to my leg." A herniated lumbar disk is suspected. Which of the following would help to confirm the suspicion? Select all that apply.

-Postural deformity -Muscle weakness -Altered tendon reflexes

The nurse is developing a plan of care for a patient who has stabilized after the emergency treatment of Guillain-Barré syndrome (GBS). What nursing intervention would receive priority for this patient?

Using the incentive spirometer as prescribed

A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect:

Acute attacks with full recovery or residual deficit upon recovery.

The nurse is aware that burr holes may be used in neurosurgical procedures. Which of the following is a reason why a neurosurgeon may choose to create a burr hole in a patient?

Aspiration of a brain abscess Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a hematoma.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees After supratentorial surgery, the nurse should elevate the client's head 30 degrees to promote venous outflow through the jugular veins.

A young adult has just been diagnosed with atonic seizures. The nurse practitioner explains to the patient that this type of seizure is characterized by:

Sudden loss of muscle tone that results in a fall.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision).

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

During assessment of a patient who has been taking dilantin for seizure management for 3 years, the nurse notices one of the side effects that should be reported. What is that side effect?

Gingival hyperplasia

A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following?

The disease has entered the late stages. In late stages, the disease affects the jaw, tongue, and larynx; speech is slurred; and chewing and swallowing become difficult. Rigidity can lead to contractures. Salivation increases, accompanied by drooling. In a small percentage of clients, the eyes roll upward or downward and stay there involuntarily (oculogyric crises) for several hours or even a few days.

A patient with Parkinson's disease is experiencing an on-off syndrome. What does the nurse recognize that the patient's clinical symptoms will be?

The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication.

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

Ineffective airway clearance

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate A dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients.

The nurse is caring for a patient on the neurological unit who is in status epilepticus. What medication does the nurse anticipate being given to halt the seizure?

IV diazepam

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

Enemas Enemas should be avoided in clients with increased ICP. The Valsalva maneuver causes increased ICP.

A client is diagnosed with amyotrophic lateral sclerosis (ALS) in the early stages. Which medication would the nurse most likely expect to be prescribed as treatment?

Riluzole Riluzole is the only medication that is approved for use in treating ALS.

A nurse is assessing a client with Parkinson's disease. Which of the following would the nurse expect to find?

Slowing of activity Clients with Parkinson's disease typically manifest bradykinesia (slowing of all active movement), a propulsive, forward leaning gait, tremors that disappear with active movement, and muscle rigidity.

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

Check the equipment.

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk?

choreiform movements Choreiform, described as uncontrollable writhing and twisting of the body, is a typical sign associated with Huntington disease and would be a risk for injury.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary." The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

An older adult man has been diagnosed with Parkinson's disease and has begun treatment with levodopa and carbidopa. When providing health education about his new medication regimen, what should the nurse teach the man?

"This medication helps significantly but the benefits tend to decrease over time."

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply.

-Decreased glucose -Increased protein -Increased white blood cells

The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.

-Loosening constrictive clothing -Positioning the patient on his or her side with head flexed forward -Providing for privacy

A client with a herniated lumbar disc has asked about nonsurgical strategies to help with mobility. What strategies will the nurse teach the client? Select all that apply.

-Muscle relaxants -Physical therapy -Weight reduction Nonsteroidal anti-inflammatory medications

A patient diagnosed with meningitis would be expected to exhibit which of the following clinical manifestations? Select all that apply.

-Nuchal rigidity -Positive Kernig's sign -Positive Brudzinski's sign -Photophobia

A patient with herpes simplex virus (HSV) encephalitis has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process?

Acyclovir (Zovirax)

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return.

A patient with Parkinson's disease asks the nurse what can be done to prevent problems with bowel elimination. What would be an intervention that would assist this patient with a regular stool pattern?

Adopt a diet with moderate fiber intake.

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Antibodies are removed from the plasma.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye. An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety.

Which phase of a migraine headache usually lasts less than an hour?

Aura

A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?

Confusion In the postictal state (after the seizure), the patient is often confused, hard to arouse, and may sleep for hours.

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

A patient is being treated in hospital for St. Louis encephalitis. When planning this patient's care, the nurse should be aware that this specific variant of encephalitis creates a potential for what nursing diagnosis?

Excess fluid volume A unique clinical feature of St. Louis encephalitis is the development of syndrome of inappropriate antidiuretic hormone secretion (SIADH) with hyponatremia in 25% to 33% of affected patients

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours.

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease.

A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options.

Seizures Death Permanent neurologic dysfunction Impaired cellular activity

A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?

Semisolid food with thick liquids

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

An infusion of phenytoin (Dilantin) has been ordered for a patient whose brain tumor has just caused a seizure. The patient has been receiving D5W at 100 mL/hour to this point and has only one IV access site at this point. How should the nurse prepare to administer this drug to the patient?

Thoroughly flush the patient's IV with normal saline.

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

Tremors and muscle rigidity The cardinal signs of PD are tremor, rigidity, akinesia/bradykinesia, and postural disturbances.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?

Trigeminal neuralgia Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40.

A client with meningitis has a history of seizures. Which action by the nurse is appropriate while the client is actively seizing?

Turn the client to the side

A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?

Urinary tract infection

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin.

Which nursing interventions might need to be considered in a care plan for a client with advanced multiple sclerosis? Select all that apply.

-Ensure access to a language board when communicating with the client. -Establish a voiding time schedule. -Encourage the client to walk with feet wide apart.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?

Elevate the head of the bed. The first action would be to elevate the head of the bed to promote venous drainage of blood and cerebral spinal fluid (CSF).

The nurse identifies a nursing diagnosis of imbalanced nutrition, less than body requirements related to difficulty in chewing and swallowing for a client with Parkinson's disease. Which of the following would be most appropriate for the nurse to integrate into the client's plan of care?

Encourage the client to massage the facial and neck muscles before eating.

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis.

A nurse is monitoring a client with Guillain-Barré syndrome. The nurse should assess the client for which responses? Select all that apply.

-respiratory distress -difficulty swallowing

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Uneven, labored respirations

A female patient has presented to the emergency department (ED) with complaints of a high fever and severe headache. The patient states that acetaminophen has had no appreciable effect on either symptom. The triage nurse recognizes the need to perform a rapid assessment for possible meningitis and should ask which of the following questions:

"Are you having stiffness or pain in your neck?" Nuchal rigidity is an early sign of meningitis that is seen in 30% to 70% of patients.

Which anticholinergic agent is used to control tremor and rigidity in Parkinson disease?

Benztropine Mesylate

Which is often the most disabling clinical manifestation of multiple sclerosis?

Fatigue

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?

Tensilon test Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low Normal cerebral perfusion pressure (CPP) is 70 to 100 mm Hg.

The nurse is caring for a client who is taking a medication that affects the function of the neurotransmitter norepinephrine. The client asks, "What does norepinephrine normally do in the body?" What should the nurse include in the response? Select all that apply.

-Affects attention and concentration -Raises energy level -Heightens arousal

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.

-Demonstrate daily muscle stretching exercises. -Apply warm compresses to the affected areas. -Allow the patient adequate time to perform exercises

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?

Initiate seizure precautions. A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

A client is admitted to the hospital with pneumonia. He has a history of Parkinson disease, which his family says is worsening. Which assessment should the nurse expect?

Impaired speech

A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication?

Lamictal

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed with magnetic resonance imaging.

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?

Urine retention or incontinence Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery.

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.