NCLEX Neuro disorders

A client diagnosed with a brain tumor experiences a generalized seizure while sitting in a chair. How should the nurse intervene first?

Assist the client to a side-lying position on the floor, and protect her with linens.

If someone with GBS has voiding problems, what should you be concerned about?

Get a vent in place because diaphragm is going to be affected next.

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

"Avoid hot baths and showers."

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction?

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

When teaching a client about levodopa and carbidopa (Sinemet) therapy for Parkinson's disease, the nurse should include which instruction?

"Be aware that your urine may appear darker than usual."

When teaching patients who are at risk for Bell's palsy because of previous herpes simplex infection, which information should the nurse include?

"Call the doctor if pain or herpes lesions occur near the ear." rational: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

What is the therapeutic level of DILANTIN?

"Dial at Ten" 10-20 = therapeutic level

A client with multiple sclerosis who is unable to bathe herself complains that other staff members haven't been bathing her. How should the nurse respond to this client's complaint?

"I'm sorry you haven't been bathed. I'm available to bathe you now."

A client with idiopathic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Client teaching about this drug should include which instruction?

"Schedule follow-up visits with your physician for blood tests."

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. What should the nurse tell the client about the paralysis?

"The paralysis caused by this disease is temporary."

When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care:

-Urinary catheter care -Continuous cardiac monitoring -Avoidance of cool room temperature -Administration of H2 receptor blockers rational: The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.

What are the signs and symptoms of Parkinson's Disease?

1. Mask like blank expression 2. pill rolling 3. Shuffling gait 4. propulsive gait 5. tremors 6. bradykinesia 7. loss of ability to swallow 8. decreased blinking 9. muscle rigidity

What should you make sure to discuss with someone who has multiple sclerosis?

Advanced directives because patient will eventually end up on vent and the use of a peak flow meter.

What is motor aphasia?

Also known as EXPRESSIVE APHASIA, Broca's area, it is the inability to speak or write. However, patient can comprehend the spoken or written form of communication.

Why should the patient with trigeminal neuralgia chew on the unaffected side? What is the outcome?

Because the unaffected side is painful. Patient would lose weight. The outcome should be weight gain as a result of chewing on unaffected side and eating a high calorie, high protein diet like custard, milk and eggs.

How does GBS progress?

Begins in lower extremities and ascends bilaterally starting with weakness, then ataxia, then bilateral paresthesia progressing in paralysis.

What is important to teach pregnant women about DILANTIN?

DO NOT TAKE, because it causes birth defects.

A client is hospitalized with Guillain-Barré syndrome. Which data collection finding is most significant?

Even, unlabored respirations

A client with seizure disorder comes to the physician's office for a routine checkup. Knowing that the client takes phenytoin (Dilantin) to control seizures, the nurse assesses for which common adverse drug reaction?

Excessive gum tissue growth

What is the proper way to give DILANTIN?

IV Push: (not compatible with IV solutions), give closest insertion site, flush/push/flush

A physician diagnoses a client with myasthenia gravis and prescribes pyridostigmine (Mestinon), 60 mg by mouth every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine?

Intestinal obstruction

What drug is commonly taken to help Parkinson's symptoms? What are the Considerations?

LEVODOPA. Watch for hypotension and place TED hose on your patient to prevent further complications.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

Following a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first?

Notify the patient's health care provider. rational: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

When the nurse is assessing a patient with myasthenia gravis, which action will be most important to take?

Observe respiratory effort. rational: Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. Which action will the nurse take first?

Obtain oxygen saturation. rational: Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.

What occurs in the post-ictal period?

Patient sleeps for several hours after seizure. Do not call physician because this is expected.

A patient who is suspected of having an epidural hematoma is admitted to the emergency department. Which action will the nurse plan to take?

Prepare the patient for immediate craniotomy. rational: The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If intracranial pressure (ICP) is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.

What are the people with myasthenia gravis always at risk for?

Respiratory Distress

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 client is having a tonic-clonic seizure. What should the nurse do first?

Take measures to prevent injury.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?

Teach the purpose of a prescribed bowel program. rational: Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

The patient has a history of a recent acute myocardial infarction. rational: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it is an indication that sumatriptan would be an inappropriate treatment.

Is someone with aphasia still considered competent?

YES

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is ______________

observing respiratory rate and effort. rational: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in a room set at a comfortable temperature.

A client who is learning to use a cane is afraid it will slip with ambulations causing a fall. the nurse provides the client with the greatest reassurance by telling the client that:

the cane has a flared tip with concentric rings to provide stability

The physician suspects myasthenia gravis in a client with chronic fatigue, muscle weakness, and ptosis. Myasthenia gravis is associated with:

thymus gland hyperplasia.

When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about _______________

triggers that lead to facial pain. rational: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences.

The nurse is preparing a client for a computed tomography (CT) scan, which requires infusion of radiopaque dye. Which question is important for the nurse to ask?

"Are you allergic to seafood or iodine?"

Which action should the nurse take when assessing a patient with trigeminal neuralgia?

Examine the mouth and teeth thoroughly. rational: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

What makes someone with myasthenia gravis worse?

Exercise and Infection

What drug is used by someone experiencing autonomic dysreflexia symptoms at home?

PROCARDIA to decrease BP. Prick and squeeze under tongue. Works quickly and raise head of bed.

A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?

The patient's blood pressure is 90/50 mm Hg. rational: To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

What should you document for a seizure occurrence?

The time it occurred and lasted and what parts of the body were affected.

Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?

Uncontrolled head movement rational: Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding should the nurse consider abnormal?

Urine retention or incontinence

What should you watch for with TEGETROL?

Used as an anticonvulsant for seizure prevention. Monitor CBC d/t bone marrow suppression and watch for infection

The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

Vision changes

The nurse is planning care for a client with multiple sclerosis. Which three problems should the nurse expect the client to experience?

Visual disturbances Balance problems Mood disorders

How is multiple sclerosis treated?

With steroids when active. Patient then becomes immunocompromised.

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

a positive edrophonium (Tensilon) test.

The nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy.

When evaluating a patient with trigeminal neuralgia who has had a glycerol rhizotomy, the nurse will ______________

question the patient about social activities with family and friends. rational: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient's behavior is to _______________

respect the patient's desire and arrange for privacy at mealtimes. rational: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room:

-Siderail pads -Oxygen mask -Suction tubing rational: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.

A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care:

-Use an elevated toilet seat -Cut patient's food into small pieces -Place an arm chair at the patient's bedside rational: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

How should you assist with lumbar puncture?

1) Obtain informed consent 2) Have patient empty bladder 3) Explain that she will be injected with a local anesthetic and she may feel pressure during the procedure. 4) Place patient in lateral recumbent position with knees flexed toward abdomen. Help patient to remain in that position. 5) When procedure is over, change to dorsal recumbent and monitor 6) Encourage fluids to reduce headache. 7) You should also label the tubes removed from the body. Discard 1st and 2nd tubes, 3rd tube goes to lab because it does not have any contamination.

What nursing interventions should be implemented for someone with aphasia?

1) Stand in front of client 2) Speak clearly, slowly. 3) Do not shout or speak loudly. They can hear. 4) Be patient and give client time to respond 5) Use nonverbal communication, e.g. touche, smile 6) Assist client with motor aphasia to practice simple words, 7) Listen carefully 8) Provide simple directions 9) Involve family in practice 10) Show picture cards to help convey a message

What are the signs and symptoms of MYASTHENIA GRAVIS?

1. bobblehead 2. ptosis 3. diplopia 4. slow speech 5. frowning 6. decreased tongue movement 7. drooling 8. pupils slowly react 9. increased frowning 10. decreased chewing

What are the signs and symptoms of multiple sclerosis?

1. tinnitus 2. decreased hearing 3. urinary retention 4. spastic bladder 5. constipation 6. nystagmus 7. diplopia 8. blurred vision 9. dysarthria 10. dysphagia 11. numbness 12. tingling 13. weakness 14. paralysis 15. muscle spasticity 16. ataxia 17. vertigo

A client who's receiving phenytoin (Dilantin) to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

10 to 20 mcg/ml

For a client with a head injury whose neck has been stabilized, the preferred bed position is:

30-degree head elevation.

What is sensory aphasia?

Also known as RECEPTIVE APHASIA, a patient cannot understand oral or written forms of communication.

Which action will the nurse include in the plan of care when caring for a patient who is experiencing trigeminal neuralgia?

Assess intake and output and dietary intake. rational: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

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?

Edrophonium (Tensilon)

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

How can you keep your patient safe during seizure?

Have airway open, clear harmful objects, assess respirations and then pulse. Do not restrain patient during seizure. Do not try to open clenched jaw. Do not move unless it is unsafe not to move. Do not suction until motor activity stops.

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

A client with tonic-clonic seizure disorder is being discharged with a prescription for phenytoin (Dilantin). Which instructions about phenytoin should the nurse give this client?

Monitor for skin rash. Perform good oral hygiene, including daily brushing and flossing., Periodic follow-up blood work is necessary. Report to the physician problems with walking and coordination, slurred speech, or nausea.

What are the risk factors for Guillain Barre Syndrome?

More common among the 20-50 age group, associated with swine flu immunizations, frequently preceded by mild respiratory or intestinal infection.

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

Passive range of motion to extremities q8hr rational: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

What kind of death does a person with multiple sclerosis normally die from?

Respiratory. Watch for hypoxia, restlessness, and agitation.

The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement?

Schedule the medication before meals.

What is DILANTIN used for?

Seizure prevention

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

The patient has continuous drooling of saliva. rational: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

The client asks the nurse, "How does ergotamine (Ergostat) relieve migraine headaches?" The nurse should respond that it:

constricts cerebral blood vessels.

The nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by:

destruction of acetylcholine receptors.

A nurse is evaluating the client's use of a cane for left sided weakness. The nurse would interven if the client moves the cane with witch side as the right leg is moved?

the nurse would interven and correct if the patient moves the cane when the righ leg is moved. The cane is held 6 inches lateral to the fifth great tow. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?

Assessment of respiratory rate and depth rational: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.

A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates what type of seizure?

Atonic rational: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

When evaluating for hypovolemic shock, the nurse should be aware of which of the following clinical manifestations? a) Hypertension b) Bradycardia c) Bounding pulse d) Hypotension

Hypotension Explanation: The nurse should be alert to a weak pulse (thread), decreased blood pressure, decreased urine output, rapid, shallow respirations, and elevated heart rate.

The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to _______________

ask simple questions that the patient can answer with "yes" or "no." rational: Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. In this syndrome, polyneuritis leads to progressive motor, sensory, and cranial nerve dysfunction. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

What is myasthenia gravis?

It is an autoimmune neuromuscular disease that affects the motor cranial nerves. It is the GRAVE MUSCLE WEAKNESS. Exacerbation and remissions are parts of the disease which tend to be progressive over time.

The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include ______________

oral administration of low dose aspirin therapy. rational: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.

A patient with right-sided weakness that started 90 minutes earlier is admitted to the emergency department and all these diagnostic tests are ordered. Which test should be done first?

Noncontrast computed tomography (CT) scan rational: Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine (Cogentin), 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?

"I take the medication at bedtime."

The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate that he understands the instructions?

"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain.", "If brushing my teeth is too painful, I'll try to rinse my mouth instead."

What treatment is done for seizure patients?

1) Anticonvulsants: Phebobarbital, Carbamazepine (Tegretol) or Phenytoin (Dilantin). 2) Evaluate consciousness, safety, avoid alcohol. 3) Reduce activities that stimulate and reduce stimuli; no strobe lights because it is repetitive. 4) Reorient client after seizure.

Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?

Administer lorazepam (Ativan) 4 mg IV. rational: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

What is AMYOTROPHIC LATERAL SCLEROSIS? What is important to know about it?

Also known as Lou Gehrig's Disease, it is a progressive neurological disease characterized by neuron death resulting in muscle weakness and eventually paralysis. The patient will die when respiratory paralysis reaches diaphragm so discuss advance directives and make sure to check gag reflex before feeding this patient.

What is autonomic dysreflexia? What is the cause? What are the signs and symptoms?

Also known as hyperreflexia, it is a potentially life threatening condition involving exaggeration of the sympathetic response to stimulation. The condition occurs in people with spinal cord injuries at T-6 or higher. It is triggered by a sustained stimuli such as restrictive clothing, pressure areas, FULL BLADDER, UTI or FECAL IMPACTION. Signs and symptoms above the level of injury: 1) flushed face 2) increased blood pressure 200/100 3) headache 4) distended neck veins 5) decreased heart rate 6) increased sweating, vasodilation Signs and symptoms below level of injury: 1. Pale 2. Cool 3. No sweating, vasoconstriction

What is Guillain Barre Syndrome?

An autoimmune disease of the nervous system due to damage of myelin sheath around the nerves., progresses rapidly or over 2-3 weeks, characterized by muscle weakness or symmetrical paralysis. Pig Head. Also, Landry's paralysis, an acute polyneuropathy affecting the PNS. The most typical symptoms cause change in sensation or pain, as well as dysfunction of the ANS. It can cause complications, in particularly in the respiratory muscles if the ANS is involved. It is usually triggered by an infection.

A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first?

Check the blood pressure (BP). rational: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

What should you teach a patient on DILANTIN?

Good oral hygiene and nutrition are important

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate the need to teach the patient about _____________

IV infusion of immunoglobulin (Sandoglobulin). rational: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium), 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?

In 10 to 15 minutes

In a client with amyotrophic lateral sclerosis and respiratory distress, which finding is the earliest sign of reduced oxygenation?

Increased restlessness

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

Ineffective airway clearance

While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question?

Insert nasogastric tube. rational: Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders.

What is PARKINSON'S DISEASE?

It is a progressive neurological disease with a slow onset that usually occurs after age 50, rarely occurring in the black population, and leading to a respiratory death. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra, a region of the midbrain; the cause of this cell death is unknown.

What is multiple sclerosis?

It is a progressive neurological disease with an onset among those who are at their 20's through 40's. It has a hereditary link and occurs most commonly among women. It involves the hardening of multiple nerves, and is aggravated by stress. It limits changes.

Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse?

Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg rational: The PbtO2 should be 20 to 40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2.

What kind of shoes should you recommend for a patient with Parkinson's Disease?

Shoes with 1 thread so they can slide through lie. No tennis shoes or leather bottom shoes. Slippers are good.

What is the short term treatment for diagnosis of myasthenia gravis? And for long term?

Short term is TENSILON. Long term treatment is PROSTIGMIN, an airway medication and MESTINON.

How is the diagnosis of myasthenia gravis made versus cholinergic crisis?

Since both are present with the same symptoms, administer TENSILON to differentiate one from the other. If the symptoms improve, then it is myasthenia gravis. A lack of medication, PROSTIGMIN, would then be the problem. So, increase medication. If the symptoms get worse, then it is a cholinergic crisis. Too much medication is the problem with increased Prostigmin. So provide an antidote which is ATROPIN.

A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

Start the ordered PRN oxygen at 6 L/min. rational: Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse expects which neuromuscular blocking agent to be administered?

Succinylcholine (Anectine)

A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the can by holding it with the

the client is taught to hold the cane on the opposite side of the weakness. This will be the patient's left hand. The cane is placed 6 inches lateral to the fithe toe

A client who was diagnosed with multiple sclerosis 3 years ago now presents with lower extremity weakness and heaviness. During the admission process, the client presents her advance directive, which states that she doesn't want intubation, mechanical ventilation, or tube feedings should her condition deteriorate. How should the nurse respond?

"It's important for us to have this information. You should review the document with your physician at every admission."

A client has an exacerbation of multiple sclerosis accompanied by leg spasticity. The physician prescribes dantrolene sodium (Dantrium), 25 mg by mouth daily. How soon after administration can the nurse expect to see a significant reduction in spasticity?

1 to 2 weeks

What is TRIGEMINAL NEURALGIA? What are the considerations?

A cranial nerve disorder affecting sensory branches of the trigeminal nerve (CN V). Lukewarm food, chew on unaffected side, eye care, tearing, blinking, oral hygiene, increased protein, calories, room temperature and avoid touching client.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client?

Assist the client to the floor. Turn the client to his side. Place a pillow under the client's head.

What is BELLS PALSY? What are the considerations?

Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) causing an inability to control facial muscles on the affected side. The biggest complications are pain and an eyelid that won't shut. To protect the eyes from corneal abrasions, use drops and eye patches at night or tape shut to protect.

What is the medical treatment for TRIGEMINAL NEURALGIA? What is the surgical treatment?

DILANTIN or TEGRETOL. For surgical, local nerve blocks or slow nerve transmission to decrease pain.

A client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

What are the adverse reactions from medication?

Gingival hyperplasia, GI disturbances, heptoxicity, ataxia, hypocalcemia, and decrease in vitamin D absorption

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. Which nursing diagnosis is of highest priority?

Imbalanced nutrition: less than body requirements rational: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.

A client with amyotrophic lateral sclerosis (ALS) tells the nurse, "Sometimes I feel so frustrated. I can't do anything without help!" This comment best supports which nursing diagnosis?

Powerlessness

What kinds of food or vitamins should someone with Parkinson's avoid? Why?

Spinach, bananas, fish and pepper. Also, Vitamin B6, because they all deactivate LEVODOPA, the precursor to the neurotransmitters dopamine, norepinephrine (noradrenaline), and epinephrine (adrenaline) collectively known as catecholamines

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move him to a flat surface and turn him on his side.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG).

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

A client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), 2 mg by mouth twice daily. In addition to being used to relieve painful muscle spasms, diazepam also is recommended for:

treatment of spasticity associated with spinal cord lesions.