Chapter 64: Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? "Avoid hot baths and showers." "Restrict fluid intake to 1,500 ml/day." "Limit your fruit and vegetable intake." "Avoid taking daytime naps."

"Avoid hot baths and showers." The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate? "Eat plenty of fruits and vegetables throughout the day." "Keep your fluid intake to fewer than 2 liters per day." "Do not delay the urge to move your bowels when it occurs." "Try to increase your activity level a bit more."

"Keep your fluid intake to fewer than 2 liters per day." To promote bowel elimination, the nurse should suggest a daily fluid intake of 2 to 3 liters per day unless contraindicated and encourage the patient to respond to the urge to defecate. Increasing the intake of fruits and vegetables and encouraging an increase in physical activity are appropriate to stimulate peristalsis.

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? "It must be hard to accept the permanency of your paralysis." "You'll be permanently paralyzed; however, you won't have any sensory loss." "The paralysis caused by this disease is temporary." "You'll first regain use of your legs and then your arms."

"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.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention? Encourage oral fluid intake. Administer prescribed antibiotics. Assess the CSF fluid laboratory test results. Prepare the client for a CT scan.

Administer prescribed antibiotics. A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.

A nurse is working with a patient to establish a bowel training program. Based on the nurse's understanding of bowel function, the nurse would suggest planning for bowel evacuation at which time? Before bed Upon arising After breakfast Around lunchtime

After breakfast Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation.

The nurse is evaluating the laboratory values of a client whose nursing diagnosis is "risk for impaired skin integrity." Which of the following values places the client at greatest risk? Hematocrit, 43.5 Potassium, 3.0 Albumin, 1.5 g/dL Hemoglobin, 10.5

Albumin, 1.5 g/dL Clients with albumen concentrations <3 g/dL are associated with hypoalbuminemic tissue edema and increased risk of impaired skin integrity related to pressure ulcers. Anemia can also increase the risk for pressure ulcers; however, a hemoglobin of 10.5 and a hematocrit of 43.5 are within the normal range. Although potassium of 3.0 is low, this does not put the client at increased risk for impaired skin integrity.

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? Only a very small percentage (5% to 8%) of clients recover completely. No one with Guillain-Barre syndrome recovers completely. Approximately 60% to 75% of clients recover completely. Usually 100% of clients recover completely.

Approximately 60% to 75% of clients recover completely. Results of studies on Guillain-Barre syndrome indicate that 60% to 75% of clients recover completely.

Which nursing intervention is the priority for a client in myasthenic crisis? Administering intravenous immunoglobin (IVIG) per orders Ensuring adequate nutritional support Assessing respiratory effort Preparing for plasmapheresis

Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

The nurse is assessing a male client with multiple sclerosis (MS). What education would the nurse provide to assist the client in managing this disease? Select all that apply. Treatment of any episodes of depression Recommend bone mineral density testing Participation in occupational therapy Effective treatment of anemia Avoidance of hot temperatures

Avoidance of hot temperatures Treatment of any episodes of depression Effective treatment of anemia Participation in occupational therapy Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the central nervous system (CNS). Fatigue affects most people with MS and is often the most disabling symptom. Heat, depression, anemia, deconditioning, and medication may contribute to fatigue. Avoiding high temperatures, effective treatment of depression and anemia, a change in medication, as well as occupational and physical therapy may help manage fatigue. Pain is another common symptom of MS. Bone mineral testing is recommended for women with MS who are perimenopausal. This group of clients are likely to have pain related to osteoporosis.

The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use? The Braden Scale The Pulses Profile Patient evaluation conference system Barthel Index

Barthel Index The Barthel Index (Mahoney & Barthel, 1965) is used to measure the patient's level of independence in ADLs, continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. The Patient Evaluation Conference System (PECS) (Harvey, Hollis, & Jellinek, 1981), which contains 15 categories, is a comprehensive assessment scale that includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. The PULSES profile (Granger, Albrecht, & Hamilton, 1979) is used to assess physical condition (e.g., health/ illness status), upper extremity functions (e.g., eating, bathing), lower extremity functions (e.g., transfer, ambulation), sensory function (e.g., vision, hearing, speech), bowel and bladder function (i.e., control of bowel or bladder), and situational factors (e.g., social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). Scales such as the Braden scale (Table 10-3) or Norton scale (Norton, McLaren, & Exon-Smith, 1962) may be used to facilitate systematic assessment and quantification of a patient's risk for pressure ulcer

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following? Client does not reach the toilet before experiencing voiding. Client leaks urine when coughing or sneezing. Client experiences a strong perceived urge to void. Client lacks the sensory awareness about the need to void.

Client does not reach the toilet before experiencing voiding. Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario? Avonex Copaxone Novantrone Betaseron

Copaxone Copaxone reduces the rate of relapse in the RR course of MS. It decreases the number of plaques noted on MRI and increases the time between relapses. Copaxone is administered subcutaneously daily. It acts by increasing the antigen-specific suppressor T cells. Side effects and injection site reactions are rare. Copaxone is an option for those with an RR course; however, it may take 6 months for evidence of an immune response to appear.

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain? Parkinson disease Huntington disease Multiple sclerosis Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis 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. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Numbness Patchy blindness Loss of proprioception Diplopia and ptosis

Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

The nurse is initiating a bladder-training schedule for a patient. What intervention can be provided for optimal success? (Select all that apply.) Administer a diuretic every morning. Teach bladder massage to increase intra-abdominal pressure. Require the patient to restrict fluid intake during the day to decrease voiding. Give up to 3,000 mL of fluid daily. Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void.

Encourage the patient to wait 30 minutes after drinking a measured amount of fluid before attempting to void. Give up to 3,000 mL of fluid daily. Teach bladder massage to increase intra-abdominal pressure. At no time should the fluid intake be restricted to decrease the frequency of urination. Sufficient fluid intake (2,000 to 3,000 mL per day, according to patient needs) must be ensured. To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be administered about 30 minutes before voiding attempts. In addition, most of the fluids should be consumed before evening to minimize the need to void frequently during the night. Massage of the abdomen can be effective in increasing intra-abdominal pressure and thus promoting the urge to void. The goal of bladder training is to restore the bladder to normal function, so diuretics should not be used.

Bell palsy is a disorder of which cranial nerve? Trigeminal (V) Facial (VII) Vestibulocochlear (VIII) Vagus (X)

Facial (VII) Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? Fatigue and depression Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Facial distortion and pain

Facial distortion and pain Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? Barthel Index PULSES profile Functional Independence Measure Patient Evaluation Conference System

Functional Independence Measure One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (trade marked- FIM), a minimum data set consisting of 18 items. The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next? Obtain a transfer board to ease the change. Have the patient lie back down. Encourage the patient to take deep breaths. Have the patient stand up immediately.

Have the patient lie back down. The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in position.

The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? Diplopia that is constant Ptosis that is more pronounced at the end of the day Nuchal rigidity Headache that is worse in the morning

Headache that is worse in the morning The most prevailing symptom of a brain abscess is headache, which is usually worse in the early morning. Ptosis and diplopia are seen in clients with myasthenia gravis. Nuchal rigidity is seen in clients with meningitis.

A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take? Flex the patient's thigh on his abdomen and assess the extension of the leg. Assess the patient's sensitivity to light. Help the patient flex his neck and observe for flexion of the hips and knees. Support the patient's neck through normal range of motion and evaluate stiffness.

Help the patient flex his neck and observe for flexion of the hips and knees. A positive Brudzinski sign: When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity.

A nurse is assessing a client for potential problems related to function and mobility. Which of the following would alert the nurse to identify a potential problem related to function or movement? Holds onto the furniture when walking in the house Uses the handrail on one side to go down the stairs Keeps the head erect while combing the hair Lifts one leg by raising it off the ground

Holds onto the furniture when walking in the house Holding onto the furniture or other objects in the room when ambulating suggests difficulty with movement. Using both hands on a handrail while going down stairs, lifting one leg by using the other leg as support, or tilting the head to reach the back of the side while combing would suggest problems with function and mobility.

The nurse is creating a bowel evacuation program for a paraplegic client. When should the nurse plan to administer a suppository? Just before breakfast Right before bed 1 hour before dinner 30 minutes after lunch

Just before breakfast The best time to plan for bowel evacuation when establishing a bowel regime is 30 minutes after breakfast to take advantage of natural reflexes. Suppositories to promote evacuation should be administered 30 minutes before the desired evacuation time. Therefore, the nurse in this example should plan for the suppository to be administered just before the client's breakfast.

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? Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort Evaluation of nutritional status and metabolic state Lung auscultation and measurement of vital capacity and tidal volume

Lung auscultation and measurement of vital capacity and tidal volume 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.

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address? Skin color Tissue perfusion Drainage Moisture

Moisture Although skin color, tissue perfusion, and drainage are important assessment areas to address, the Braden scale uses the following categories to predict pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Which of the following is considered a central nervous system (CNS) disorder? Guillain-Barré Bell's palsy Multiple sclerosis Myasthenia gravis

Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

Which 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? Parkinson disease Multiple sclerosis Creutzfeldt-Jakob disease Huntington disease

Multiple sclerosis The cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Hyporeflexia and skin rash Fever and cough Muscle weakness and hyporeflexia of the lower extremities Ptosis and muscle weakness of upper extremities

Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

The most common cause of cholinergic crisis includes which of the following? Infection Undermedication Compliance with medication Overmedication

Overmedication A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.

Which therapeutic exercise is done by the nurse without assistance from the client? Active Passive Isometric Resistive

Passive Passive therapeutic exercise is carried out by the therapist or the nurse without assistance from the client. Active therapeutic exercises are accomplished by the client without assistance. Resistive exercise is carried out by the client working against resistance produced by either manual or mechanical means. Isometric exercise is described as alternately contracting and relaxing a muscle while keeping the part in a fixed position.

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process? Patient Physical therapist Nurse Physician

Patient Although the nurse, physician, and physical therapist play important roles in the rehabilitation process, the patient is a key member of the rehabilitation team, the focus of the team's efforts, and the one who determines the final outcomes of the process.

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced? Photophobia Positive Kerning sign Nuchal rigidity Positive Brudzinski sign

Positive Brudzinski sign A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury) and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely? Hyper-alertness Negative Kernig's sign Positive Brudzinski's sign Increased intake

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 positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses, not increased intake or hyper-alertness.

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation? Most care tasks required after discharge focus on the physical care. Fatigue primarily results from physical demands. Priority setting is helpful in dealing with the impact of the disability. A loss of sexual functioning correlates with a loss of sexual feeling.

Priority setting is helpful in dealing with the impact of the disability. For clients with disabilities, the nurse would emphasize the use of coping strategies and teach the patient how to cope with the disability through priority setting. A loss of sexual functioning does not necessarily correspond to a loss of sexual feeling. Rather, the physical and emotional aspects of sexuality, despite the physical loss of function, continue to be important for people with disabilities. The fatigue associated with disabilities results from numerous factors, such as the physical and emotional demands, as well as the ineffective coping, unresolved grief, disordered sleep patterns, and depression. Although the most obvious care tasks after discharge involve physical care, other elements of the caregiving role include psychosocial support and a commitment to this supportive role.

The nurse working on a rehabilitation unit rotates a client's forearm so that the palm of the hand is facing down. The nurse documents this as which type of movement? Inversion Pronation Supination Eversion

Pronation Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that runs the sole of the foot inward. Supination is rotation of the forearm so that the palm of the hand is up. Eversion is the return movement from flexion.

A nurse is preparing an in-service presentation that focuses on promoting pressure ulcer healing. The nurse is planning to include information about appropriate nutrition. Which of the following would the nurse include as important for overall tissue repair? Water Protein Zinc sulfate Vitamin C

Protein Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.

The nurse is evaluating the serum albumin of a client newly admitted on the rehabilitation unit. The nurse determines that the client's serum albumin concentration is low, indicating that the client has which deficiency? Protein Phosphorous Calcium Potassium

Protein Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)? Administering amphotericin B Initiating isolation procedures Preparing for organ donation Providing palliative care

Providing palliative care vCJD is a progressive fatal disease; no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)? Preparing for organ donation Providing supportive care Initiating isolation procedures Administering amphotericin B

Providing supportive care vCJD is a progressive fatal disease, and no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Hepatic Integumentary Renal

Renal Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

The nurse is working with a physical therapist to create a multidisciplinary plan of care for a client in a rehabilitation unit. The therapist suggests that the client would benefit from the use of light weights during shoulder exercises. The nurse incorporates this into the plan of care as which type of exercise? Passive Isometric Resistive Active-assistance

Resistive The nurse should incorporate exercise that involves the use of light weights, referred to as resistive exercise. In active-assistive exercises the client performs the exercises with assistance from the therapist. In passive exercises, the nurse performs the exercise without assistance from the client. In isometric exercises, the client alternately contracts and relaxes the muscle while keeping the part in a fixed position.

The nurse is caring for a client with Bell's palsy. Which body system will the nurse identify as the priority for this client? Musculoskeletal Neurologic Sensory Integumentary

Sensory The priority for nursing care of the client with Bell's palsy is protecting the eye from injury. The eyelid often will not close completely and the blink reflex is diminished, increasing the risk of injury from dust and foreign particles. Corneal irritation and ulcerations may occur. The condition is caused by unilateral inflammation of the 7th cranial nerve; however, the neurologic system is not at risk for additional injury or effects. The integumentary system is not affected by Bell's palsy. The facial muscles on the affected side will be paralyzed; however, this is the only area of the musculoskeletal status affected.

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk? Sedimentation rate Prothrombin time Serum albumin Serum glucose

Serum albumin Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g per dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Serum glucose is used to assess for diabetes. Prothrombin time is used to assess clotting time and monitor therapeutic levels of anticoagulation medications. Sedimentation rate is used to detect inflammation in the body.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? Speeds nerve impulse transmission Carries message to the next nerve cell Represents building block of nervous system Acts as chemical messenger

Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

In which stage is a pressure ulcer considered a partial-thickness wound? Stage III Stage II Stage IV Stage I

Stage II A stage II pressure ulcer is considered a partial-thickness wound. A stage I pressure ulcer is an area of erythema that does not blanch with pressure. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends to the underlying muscle and bone.

The nurse is reading the previous shift's documentation of an open area on the client's sacrum. The wound is documented as a partial-thickness wound whose etiology is pressure. The nurse anticipates the assessment of the client's sacrum will reveal a pressure ulcer in which stage? Stage I Stage III Stage II Stage IV

Stage II A stage II pressure ulcer is considered a partial-thickness wound. A stage I pressure ulcer is an area of erythema that does not blanch with pressure. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends to the underlying muscle and bone.

A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor? Streptococcus pneumoniae Staphylococcus aureus Hemophilus influenzae Escherichia coli

Streptococcus pneumoniae The bacteria Streptococcus pneumoniae and Neisseria meningitides are responsible for 80% of cases of meningitis in adults.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Nasal cannula and oxygen Suction machine with catheters Padded tongue blade Sphygmomanometer

Suction machine with catheters MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

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. Tell the patient to smile every 4 hours. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates.

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. 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. Exposure of the face to cold and drafts is avoided.

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Serum studies Electromyogram (EMG) Tensilon test Computed tomography (CT) scan

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 presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.

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 uses a mechanical lift to climb steps. The client arranges a community service to deliver meals. The client grasps the affected arm at the wrist and raises it. The client ambulates with the assistance of one.

The client grasps the affected arm at the wrist and raises it. The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? The nurse The patient The physician The physical therapist

The patient The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process.

The nurse is caring for a client with Bell's palsy. Which of the following teaching points is a priority in the management of symptoms for this client? Use ophthalmic lubricant and protect the eye. Complete the course of antibiotics as prescribed. Encourage semiannual dental exams. Avoid stimuli that trigger pain.

Use ophthalmic lubricant and protect the eye. The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury? When an exercise program has been initiated After the physician has prescribed rehabilitative goals After the patient feels comfortable in the clinical setting With initial patient contact

With initial patient contact The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient.

To help prevent the development of an external rotation deformity of the hip in a client who must remain in bed for any period of time, the most appropriate nursing action would be to use a trochanter roll extending from the crest of the ilium to the midthigh. pillows under the lower legs. a hip-abductor pillow. a footboard.

a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip. Pillows under the legs or a footboard will not prevent the hips from rotating externally. A hip-abductor pillow is used for the patient after total hip replacement surgery.

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: choking. infection. complications. falls.

complications. 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.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at preventing muscular atrophy. preventing renal insufficiency. maintaining hemodynamic stability and adequate cardiac output. controlling seizures and increased intracranial pressure.

controlling seizures and increased intracranial pressure. There is no specific medication for arbovirus encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: document the condition of the client's skin. contact the client's family. do nothing; the client's skin is intact. give the client a donut ring to reduce pressure on the affected area.

document the condition of the client's skin. The client's warm, red skin is consistent with a stage I pressure ulcer. Documenting the findings will provide a permanent record of the condition. If the nurse fails to take action, the client may experience further skin trauma. Donut rings reduce circulation to the sacral area when the client sits on them; they're contraindicated in this instance. There's no reason for the nurse to contact the client's family at this time; doing so might violate the client's right of privacy.

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? immediately after 1 week in 2 to 3 days upon transfer to a rehabilitation unit

immediately Beginning basic rehabilitation during the acute phase is an important nursing function. 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 type of therapeutic exercise, performed by a client, in which the muscle alternately contracts and relaxes is active-assistive. resistive. passive. isometric.

isometric. Isometric exercises consist of alternately contracting and relaxing a muscle while keeping the part in a fixed position. Resistive exercises are carried out by the client working against resistance produced by either manual or mechanical means. Passive exercises are carried out by the therapist or the nurse without assistance from the client. Active-assistive exercises are carried out by the client with the assistance of the therapist or the nurse.

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms indicate renal toxicity and a worsening condition. are primarily associated with infection with Coccidioides immitis and Aspergillus. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures.

may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin. Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine and acetaminophen approximately 30 minutes before the administration of amphotericin B may prevent these side effects. Renal toxicity due to amphotericin B is dose limiting. Monitoring serum creatinine and blood urea nitrogen levels may alert the nurse to the development of renal insufficiency and the need to address the clients' renal status. Vascular changes are associated with C. immitis and Aspergillus. Manifestations of vascular change may include arteritis or cerebral infarction. Blood and CSF cultures help diagnosis fungal encephalitis.

The nurse is performing passive range-of-motion exercises with a client on a rehabilitation unit. The nurse takes the client's right hand and touches the thumb to each finger. Later, the nurse documents this range-of-motion activity as palmar flexion. opposition. supination. inversion.

opposition. The nurse should document the activity as opposition, which is defined as touching the thumb to each finger on a hand. Inversion is turning the sole of the foot inward. Palmar flexion is bending the hand in the direction of the palm. Supination is rotation of the forearm so that the palm of the hand is facing up.

Rotation of the forearm so that the palm of the hand is down is termed supination. pronation. eversion. inversion.

pronation. Pronation is the rotation of the forearm so that the palm of the hand is down. Inversion is movement that turns the sole of the foot inward. Supination is rotation of the forearm so that the palm of the hand is up. Eversion is the return movement from flexion.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: rest in an air-conditioned room. avoid naps during the day. increase the dose of muscle relaxants. take a hot bath.

rest in an air-conditioned room. Fatigue is a common symptom in 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, ordered to reduce spasticity, can cause drowsiness and fatigue. 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.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: total incontinence. stress incontinence. functional incontinence. reflex incontinence.

stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.