Brunner Chapter 64

12. The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what issue? A. Genetic dysfunction B. Upper and lower motor neuron lesions C. Decreased conduction of impulses in an upper motor neuron lesion D. A lower motor neuron lesion

ANS: D Rationale: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder. A combined upper and lower neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

26. The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? A. Suctioning secretions B. Facilitating ABG analysis C. Providing ventilatory assistance D. Administering tube feedings

ANS: C Rationale: Providing ventilatory assistance takes precedence in the immediate management of the client with myasthenic crisis. It may be necessary to suction secretions and/or provide tube feedings, but they are not the priority for this client. ABG analysis will be done, but this is also not the priority.

23. A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? A. Serial assessments of hemoglobin levels B. Blood glucose monitoring C. Close monitoring of fluid balance D. Assessment of pain along dermatomes

ANS: C Rationale: A unique clinical feature of St. Louis encephalitis is SIADH with hyponatremia. As such, it is important to monitor the client's intake and output closely.

34. A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client? A. Older adults are often vague historians. B. Older adults have fewer peripheral nerves than younger adults. C. Many older adults are hesitant to admit that their body is changing. D. Many symptoms can be the result of normal aging process.

ANS: D Rationale: The diagnosis of peripheral neuropathy in the geriatric population is challenging because many symptoms, such as decreased reflexes, can be associated with the normal aging process. In this scenario, the client has come to the clinic seeking help for this problem; this does not indicate a desire on the part of the client to withhold information from the health care giver. The normal aging process does not include a diminishing number of peripheral nerves.

7. The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching

ANS: D Rationale: A client diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The client should participate in daily muscle stretching to help alleviate and relax muscle spasms.

16. A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

ANS: D Rationale: The symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease.

6. The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

ANS: A Rationale: MS 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. The cause of MS is not known, and the disease affects twice as many women as men

5. A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? A. Applying a protective eye shield at night B. Chewing on the affected side to prevent unilateral neglect C. Avoiding the use of analgesics whenever possible D. Avoiding brushing the teeth

ANS: A Rationale: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The client should be encouraged to eat on the unaffected side due to swallowing difficulties. Analgesics are used to control the facial pain. The client should continue to provide self-care including oral hygiene.

28. The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

ANS: A Rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the client's concerns by wholly deferring to the health care provider.

32. A client with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This client's nursing care should involve which of the following? A. Protection of the affected limb from injury B. Passive and active ROM exercises for the affected limb C. Education about improvements to glycemic control D. Interventions to prevent contractures

ANS: A Rationale: Nursing care involves protection of the affected limb or area from injury, as well as appropriate client teaching about mononeuropathy and its treatment. Nursing care for this client does not likely involve exercises or assistive devices, since these are unrelated to the etiology of the disease. Improvements to diabetes management may or may not be necessary.

19. The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

ANS: A Rationale: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision.

25. The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? A. Increased muscle strength B. Decreased pain C. Improved GI function D. Improved cognition

ANS: A Rationale: The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue. The drug is not intended to treat pain, or cognitive or GI functions.

2. The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? A. Washing the face B. Exposing the skin to sunlight C. Using artificial tears D. Drinking large amounts of fluids

ANS: A Rationale: Washing the face should be avoided if possible because this activity can trigger an attack of pain in a client with trigeminal neuralgia. Using artificial tears would be an appropriate behavior. Exposing the skin to sunlight would not be harmful to this client. Temperature extremes in beverages should be avoided.

24. The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

ANS: A, C, D Rationale: Older adult clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite.

10. The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? A. Tinnitus B. Facial paralysis C. Pain at the base of the tongue D. Diplopia

ANS: B Rationale: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. It does not result in diplopia, pain at the base of the tongue, or tinnitus.

35. A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

ANS: B Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration

14. To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? A. Concurrent use of calcium supplements is contraindicated. B. Blood levels of the drug must be monitored. C. The drug is likely to cause hyperactivity and agitation. D. Carbamazepine can cause tinnitus during the first few days of treatment.

ANS: B Rationale: Side effects of carbamazepine include nausea, dizziness, drowsiness, and aplastic anemia. The client must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of the drug

29. A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? A. Permanent improvement after 4 to 6 months of treatment B. Symptom improvement that lasts a few weeks after TPE ceases C. Permanent improvement after 60 to 90 treatments D. Gradual improvement over several months

ANS: B Rationale: Symptoms improve in 75% of clients undergoing TPE; however, improvement lasts only a few weeks after treatment is completed.

8. A client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this medication? A. Carbamazepine is not known to have serious adverse effects. B. The client should be monitored for bone marrow depression. . Side effects of the medication include renal dysfunction. D. The medication should be first taken in the maximum dosage form to be effective

ANS: B Rationale: The anticonvulsant agents carbamazepine and phenytoin relieve pain in most clients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Side effects include nausea, dizziness, drowsiness, and aplastic anemia. Carbamazepine should be gradually increased until pain relief is obtained.

15. A client with herpes simplex virus encephalitis (HSV) 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? A. Cyclosporine B. Acyclovir C. Cyclobenzaprine D. Ampicillin

ANS: B Rationale: Antiviral agents, acyclovir and ganciclovir, are the medications of choice in the treatment of HSV. The mode of action is the inhibition of viral DNA replication. To prevent relapse, treatment would continue for up to 3 weeks. Cyclosporine is an immunosuppressant and antirheumatic. Cyclobenzaprine is a centrally acting skeletal muscle relaxant. Ampicillin, an antibiotic, is ineffective against viruses.

33. A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

ANS: B Rationale: Baclofen, a -aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities

1. A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis? A. Pain upon ankle dorsiflexion of the foot B. Neck flexion produces flexion of knees and hips C. Inability to stand with eyes closed and arms extended without swaying D. Numbness and tingling in the lower extremities

ANS: B Rationale: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

3. The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

ANS: B Rationale: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.

9. A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection? A. Negative Brudzinski sign B. Positive Kernig sign C. Hyperpatellar reflex D. Sluggish pupil reaction

ANS: B Rationale: Meningeal irritation results in a number of well-recognized signs commonly seen in meningitis, such as a positive Kernig sign, a positive Brudzinski sign, and photophobia. Hyperpatellar reflex and a sluggish pupil reaction are not commonly recognized signs of meningitis

20. A 69-year-old client is brought to the ED by ambulance because a family member found the client lying on the floor disoriented and lethargic. The health care provider suspects bacterial meningitis and admits the client to the ICU. What interventions should the nurse perform? Select all that apply. A. Obtain a blood type and cross-match. B. Administer antipyretics as prescribed. C. Perform frequent neurologic assessments. D. Monitor pain levels and administer analgesics. E. Place the client in positive pressure isolation

ANS: B, C, D Rationale: Clients with meningitis require antipyretics and analgesia to treat fever and pain. The client's neurologic status must be monitored closely. Transfusions are not anticipated. Infection control precautions are implemented, but positive pressure isolation is not necessary because the client is not immunocompromised.

36. A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? A. The client will likely require lifelong treatment with anticholinergic medications. B. The client has a disproportionate risk of developing myasthenia gravis later in life. C. The client needs to be assessed for MS. D. The disease is self-limiting and the client will achieve pain relief over time.

ANS: C Rationale: Clients that develop trigeminal neuralgia before age 50 should be evaluated for the coexistent of MS because trigeminal neuralgia occurs in approximately 5% of clients with MS. Treatment does not include anticholinergics and the disease is not self-limiting. Trigeminal neuralgia is not associated with an increased risk of myasthenia gravis.

13. A client with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this client? A. Cerebral angiography B. ABG analysis C. CT D. EEG

ANS: D Rationale: The EEG reveals a characteristic pattern over the duration of CJD. A CT scan may be used to rule out disorders that may mimic the symptoms of CJD. ABGs would not be necessary until the later stages of CJD; they would not be utilized as a diagnostic test. Cerebral angiography is not used to diagnose CJD

18. A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B. Flexor spasm, clonus, and negative Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

ANS: C Rationale: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski reflex is found in MS. Abdominal reflexes are absent with MS.

17. A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? A. All at one time, to provide a longer rest period B. Before meals, to stimulate the client's appetite C. In the morning, with frequent rest periods D. Before bedtime, to promote rest

ANS: C Rationale: Procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the client may be too exhausted to eat. Procedures should be avoided near bedtime if possible

22. A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's reported headache? A. Initiating a client-controlled analgesia (PCA) of morphine sulfate B. Administering hydromorphone IV as needed C. Dimming the lights and reducing stimulation D. Distracting the client with activity

ANS: C Rationale: Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Nonopioid analgesics may be preferred. Distraction is unlikely to be effective, and may exacerbate the client's pain.

4. A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A. Administer bronchodilators as ordered. B. Remind the client of the importance of deep breathing and coughing exercises. C. Prepare to assist with intubation. D. Administer supplementary oxygen by nasal cannula.

ANS: C Rationale: For the client with Guillain-Barré syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the client's oxygenation needs

30. The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? A. Avoid watching television or using a computer for more than 1 hour at a time. B. Use over-the-counter antibiotic eye drops for at least 14 days. C. Avoid rubbing the eye on the affected side of the face. D. Rinse the eye on the affected side with normal saline daily for 1 week.

ANS: C Rationale: If the surgery results in sensory deficits to the affected side of the face, the client is instructed not to rub the eye because the pain of a resulting injury will not be detected. There is no need to limit TV viewing or to rinse the eye daily. Antibiotics may or may not be prescribed, and these would not reduce the risk of injury.

21. The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

ANS: C Rationale: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care.

37. A client presents at the clinic with pain and weakness in the hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what condition? A. Guillain-Barré syndrome B. Myasthenia gravis C. Trigeminal neuralgia D. Peripheral nerve disorder

ANS: D Rationale: The major symptoms of peripheral nerve disorders are loss of sensation, muscle atrophy, weakness, diminished reflexes, pain, and paresthesia (numbness, tingling) of the extremities. Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of pain in the area innervated by any of the three branches, but most commonly the second and third branches of the trigeminal nerve. Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin.

27. The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A. Impaired skin integrity B. Cognitive deficits C. Hemorrhage D. Autonomic dysfunction

ANS: D Rationale: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-Barré syndrome

31. A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? A. Blowing up balloons B. Deliberately frowning C. Smiling repeatedly D. Whistling

ANS: D Rationale: Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Blowing up balloons, frowning, and smiling are not considered facial exercises.

11. The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? A. Intermittent hearing loss B. Tinnitus C. Tongue enlargement D. Vocal paralysis

ANS: D Rationale: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease.