Chapter 69 Neuro

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

+ brudzinskis sign

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 admin, weakness and ptosis relieved for approx 5 minutes

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

I will stretch daily as directed by the PT

The diagnosis of multiple sclerosis is based on which test?

MRI

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

a disorder in which killer T cells and autoantibodies attack or destroy natural cells -- those calls that are "self"

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 patients behavior and don't take it personally

Myasthenia gravis occurs when antibodies attack which receptor sites?

acetylcholine

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

administer prescribed antibiotics

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

apply an eye patch to right eye

Which nursing intervention is the priority for a client in myasthenic crisis?

assess resp efforts

Which drug should be available to counteract the effect of edrophonium chloride?

atropine

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide?

avoid fatigue and stress -> may cause relapses

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

cerebellar abscess

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

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?

cretzfeldt-jakob disease

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

diplopia and ptosis

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

ensure atropine is readily available

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

facial

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?

facial distortion and pain

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

facial pain in the areas of the fifth cranial nerve

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

have you experienced any viral infections in the last month?

The nurse is assessing a client with sudden bilateral lower extremity weakness and dyskinesia. The client reports accompanying numbness and tingling episodes. Which question will the nurse ask the client to help determine the reason for the client's symptoms?

have you had a recent illness?

The nurse is assessing a client with meningitis. Which of the following signs would the nurse expect to observe?

headache and nuchal rigidity

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?

headache that is worse in the morning

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

help with ROM exercises every 8 hrs

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

herpes simplex virus

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

increased pulse rate and adventitious breath sounds

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

initiate isolation precautions

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

initiate seizure precautions

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following?

maintains effective respirations and airway clearance

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?

massage face several times daily, using gentle upward motion to maintain muscle tone

A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms

may be controlled w diphenhydramine and Tylenol 30 min before admin of amphotericin

The primary arthropod vector in North America that transmits encephalitis is the

mosquito

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

multiple sclerosis

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?

placement of feeding tube

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

positive edrophonium (tensilon) test

During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client?

prevention of joint contractures

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

provide supportive care

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?

renal

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

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

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?

suction machine w catheters

A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

tensilon

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

tensilon test

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

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

A client with 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

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

the pt will remain free of injury if a seizure does occur

The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse?

there are no guarantees, but a large portion of people survive