Course Point MS2 Chapter 64
The initial sign of skin pressure is erythema, which normally resolves in less than
1 hour.
The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days
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.
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter?
Acetylcholine
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.
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.
A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?
Cooking
Bell's palsy is a paralysis of which of the following cranial nerves?
Facial
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?
Have the patient lie back down.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus
A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?
Ischial tuberosity
The primary arthropod vector in North America that transmits encephalitis is the
mosquito.
Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?
positive brudzinski sign
A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.
presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?
"Avoid hot baths and showers."
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?"
A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective?
"I need to allow my arms and hands to support my body weight."
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?
After breakfast
The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform?
Apply warm packs to the affected area.
The rehabilitation nurse is caring for a 25-year-old client who suffered extensive injuries in a motorcycle accident. During each interaction with the client, what action should the nurse perform most frequently?
Evaluate the client's positioning.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
Initiate seizure precautions.
A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?
Moisture
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?
Multiple sclerosis
The most common cause of cholinergic crisis includes which of the following?
Overmedication
Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?
Polymerase chain reaction (PCR)
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 developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?
Repositioning the patient about once a shift
The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power?
Resistive exercises
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
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 patient
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
A neurologic deficit is best defined as a deficit of the:
central and peripheral nervous systems with decreased, impaired, or absent functioning.
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 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 with Guillain-Barré syndrome survive."
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?
A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance
A college student goes to the infirmary with a fever, headache, and a stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? Select all that apply.
A. administration of rifampin (Rifadin)B. administration of ciproflaxocin hydrochloride (Cipro)C. administration of ceftriaxone sodium (Rocephin)
A female client has been achieving significant improvements in her ADLs since beginning rehabilitation after a brain hemorrhage. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
Appraising the family's involvement in the client's ADLs.
The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?
Appropriate assistive devices
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?
Approximately 60% to 75% of clients recover completely.
For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?
Attaching braces or splints to each foot and leg
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?
Barthel Index
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.
The nurse is observing a client using a cane to ambulate. Which of the following would require the nurse to intervene?
Client moves the arm and leg on the same side together at the same time.
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?
Copaxone
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?
Creutzfeldt-Jakob disease
When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?
Debridement
A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?
Diminished dermal collagen
Bell palsy is a disorder of which cranial nerve?
Facial (VII)
Which is often the most disabling clinical manifestation of multiple sclerosis?
Fatigue
A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply.
HemiparesisSeizuresExpressive aphasia
A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. The nurse planning the client's care. Who will the client's condition affect?
Him and his entire family
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
The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?
Hyperemia
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, 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.
Which nutritional deficiency may delay wound healing?
Lack of vitamin C
A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?
Opposition
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?
Place the patient in the supine position.
The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?
Place the uppermost hip slightly forward in a position of slight abduction.
How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?
Practice meticulous hygiene measures.
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?
Priority setting is helpful in dealing with the impact of the disability.
Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?
Providing palliative care
Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)?
Providing supportive care
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?
Ptosis and diplopia
A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following?
Pushes the popliteal area against the mattress while raising the heel
Which of the following is the first-line therapy for myasthenia gravis (MG)?
Pyridostigmine bromide (Mestinon)
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?
Serum albumin
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)
Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Have a fluid intake between 2 and 4 L/day.
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
Stage II pressure ulcer
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 with catheters
A patient learning to ambulate with crutches advances both crutches and then lifts both feet, moving them forward and landing them in front of the crutches. The patient then repeats this motion. The nurse identifies this as which type of crutch gait?
Swing-through
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test
A client has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the client is admitted to a rehabilitation facility?
The ability to perform ADLs may be the key to re-entering the community.
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.
The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?
The client will experience grief in an individualized manner.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
The client will remain free of injury if a seizure does occur.
A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.
ToiletingEatingBathing
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder?
Trigeminal neuralgia
When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?
Trochanter roll
The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height?
Use the patient's height and subtract 16 inches.
When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?
With initial patient contact
Medical management of arthropod-borne virus (arboviral) encephalitis 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.
The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?
stage 3
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:
stress incontinence.
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?
vitamin C
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 physical therapist."
A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?
Neck flexion produces flexion of the knees and hips
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."
At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.
45
The nurse is planning care of a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of highest priority?
Include client in planning of care and setting of goals.
A client is suspected to have bacterial meningitis. What is the priority nursing intervention?
Administer prescribed antibiotics.
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
An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?
Isometric
The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario?
Lioresal
The diagnosis of multiple sclerosis is based on which test?
Magnetic resonance imaging (MRI)
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe?
Muscle weakness and hyporeflexia of the lower extremities
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
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?
Protein
An adult client's current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a client who has self-care deficits in ADLs?
To provide an optimal learning environment with minimal distractions
