312 Adaptive Quizes for Exam 3

The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine?

Administer via slow IV over 1 hour.

What is the most common cause of hyperaldosteronism?

An adrenal adenoma

Medications of choice in the treatment for Herpes simplex virus (HSV)?

Antiviral agents- either acyclovir (Zovirax) or ganciclovir (Cytovene)

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

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes. rationale: An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

At which of the following spinal cord injury levels does the patient have full head and neck control? C2 C3 C4 C5

C5

When high levels of plasma calcium occur, the nurse is aware that the following hormone will be secreted:

Calcitonin

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

Controlling seizures and increased intracranial pressure (ICP)

What condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease (CJD)

Antithyroid medications are not generally recommended for elderly patients because of which side effect?

Granulocytopenia

What is the most common cause of acute encephalitis in the USA?

Herpes simplex virus (HSV)

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a nasogastric (NG) tube

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

Mosquitoes

What is the most common cause of cholinergic crisis?

Overmedication (results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure)

A client has a dysfunction in one of his glands that is causing a decrease in the level of calcium in the blood. What gland should be evaluated for dysfunction?

Parathyroid gland

A positive __________ sign is a common finding in the client with meningitis.

Positive Brudzinski's sign (When the client's neck is flexed, flexion of the knees and hips is produced)

A client with symptoms of Cushing syndrome is admitted to the hospital for evaluation and treatment. The nurse is creating a plan of care for the client. Which is an appropriate nursing diagnosis?

Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as?

Severe TBI

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

A client has a decreased level of thyroid hormone being excreted. What will the feedback loop do to maintain the level of thyroid hormone required to maintain homeostatic stability?

Stimulate more hormones using the negative feedback system

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear. rationale: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. The client may have serous drainage from the nose especially immediately following the injury.

Neurological level of spinal cord injury refers to

The lowest level at which sensory and motor function is normal

Birds are vectors associated with what disease?

West Nile virus

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first? a. Apply a cooling blanket b. Initiate isolation precautions. c. Administer prescribed antibiotics.

b. Initiate isolation precautions. rationale: The signs and symptoms are consistent with bacterial meningitis. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. Safety first**

The sweat chloride test is used to confirm

cystic fibrosis

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order....?

famotidine (Pepcid)

Amphotericin B is used in the treatment of what?

fungal encephalitis

characteristics of autonomic dysreflexia?

severe HTN, bradycardia, pounding headache, sweating

Which type of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

subdural

What is the myelin sheath?

substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites (axon carries the message to the next nerve cell)

Myasthenic crisis is a...

sudden, temporary exacerbation of MG symptoms.

Cushing's triad

three classic signs—bradycardia, hypertension, and bradypnea

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits. rationale:Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

predominant risk factors for spinal cord injury (SCI)?

young age, male gender, and alcohol and drug use

The mother asks the nurse what a concussion is. What should the nurse's response be?

"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

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?

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

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." Return of motor function begins proximally and extends distally in the legs.

Septic meningitis is caused by ________ . Aseptic meningitis is caused by ____________.

- Septic meningitis is caused by bacteria. - In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or HIV.

s/s of increased intracranial pressure

- headache - vomiting - vision change (diplopia- double vision) - decreased LOC - seizures

The survival rate of Guillain-Barré syndrome is approximately ____ %

90% The client may make a full recovery or suffer from some residual deficits.

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?

30 sec after administration, the facial weakness and ptosis will be relieved for approximately 5 min.

Trigeminal neuralgia is a condition of the _____ cranial nerve that is characterized by...

5th cranial nerve; paroxysms of sudden pain in the area innervated by any of the three branches of the nerve (such as washing the face, shaving, brushing the teeth, eating, and drinking)

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities rationale: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid.

A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine rationale: impair transmission of impulses across the myoneural junction

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.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

Which disorder is characterized by a group of symptoms produced by an excess of free circulating cortisol from the adrenal cortex?

Cushing syndrome

What should the nurse explain to a client with Cushing syndrome?

Explain that the client's physical changes are a result of excessive corticosteroids, and to have a high-protein diet

A client with a 20-year history of hypothyroidism who has not been compliant with taking thyroid replacement therapy is brought into the ED with a diagnosis of myxedema coma. What client symptoms are consistent with this life-threatening event?

Hypothermia Hypoventilation Hypotension

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? What sign does the nurse look for?

Instruct family to look for signs of increased ICP The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

The nurse assesses a patient who has an obvious goiter. What type of deficiency does the nurse recognize is most likely the cause of this?

Iodine

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg. rationale: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness. rationale: Meticulous cleanliness is the best choice for preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion.

What is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?

Multiple sclerosis

thyroid gland normally produces:

T3, thyroxine (T4), and calcitonin.

Myasthenia gravis is caused by...

a lower motor neuron lesion at the myoneural junction

Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

Myasthenia gravis is characterized by...

a weakness of muscles, especially in the face and throat

Subdural hematomas are classified as...

acute, subacute, and chronic according to the rate of neurologic changes. (Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.)

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as?

Decerebrate. rationale: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid. rationale: With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

What findings would the nurse be most focused on related to Bell's palsy?

Facial distortion and pain

The nurse is reviewing a client's history which reveals that the client has had an oversecretion of growth hormone (GH) that occurred before puberty. The nurse interprets this as which of the following?

Gigantism

The diagnosis of multiple sclerosis is based on what test?

Magnetic resonance imaging (MRI) - presence of multiple plaques in the central nervous system observed on MRI

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur. rationale: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly.

While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following?

Positive Chvostek's sign

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which area will the nurse focus most heavily?

Respiratory !! rationale: bc of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. T

People in close contact with clients who have meningococcal meningitis should...

be treated with antimicrobial chemoProphylaxis (ideally within 24 hours after exposure)

A common precipitating event for myasthenic crisis is...

infection. (It can result from undermedication)

Kernig's sign and Brudzinski's sign indicate

meningitis

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function...

muscle function improves after the client receives an IV injection of Edrophonium (Tensilon)

Guillain-Barre syndrome typically begins with...

muscle weakness and diminished reflexes of the lower extremities

The initial manifestation of myasthenia gravis involves...

ocular muscles; such as diplopia (double vision) & ptosis (drooping upper eyelid - lazy eye)

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process?

Offer encouragement as the client makes progress. Involve the client actively in self care

What happens in plasmapheresis during treatment for myasthenia gravis?

antibodies are removed from plasma and the plasma is returned to the client

What is Guillain-Barré syndrome?

autoimmune attack on the peripheral myelin sheath

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? a. RR rate increase from 15 to 19 b. Temp increase from 98.0 to 99.8 c. BP 124/85 d. HR increase from 62 to 74

b. rationale: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia.

A patient is suspected of having a pheochromocytoma and is having diagnostic tests done in the hospital. What symptoms does the nurse recognize as most significant for a patient with this disorder?

Blood pressure varying between 120/86 and 240/130 mm Hg

A health care provider suspects that a thyroid nodule may be malignant. The nurse knows to prepare information for the patient based on the usual test that will be ordered to establish a diagnosis. What is that test?

Fine-needle biopsy of the thyroid gland

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume. rationale: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:

complications rationale: measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.

A client with quadriplegia's spinal shock subsides, the client will now demonstrate...

positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? a. Cardiovascular b. Endocrine c. Respiratory d. Neurovascular

d. Neurovascular system rationale: The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern.

A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?

preventing further neurologic damage

Because of the fatal outcome of vCJD, nursing care is...

primarily supportive and palliative - no treatment is available