neurological conditions EAQ- MOC (Exam 3)

Which patient actions would be responsible for a reported decrease in headache events at a follow-up clinic visit? Select all that apply. Meditating in the evenings Taking lithium each morning Performing yoga in the mornings Taking sumatriptan (Imitrex) once a day Taking a muscle relaxant before going to bed

Meditating in the evenings Performing yoga in the mornings Taking sumatriptan (Imitrex) once a day Practicing relaxation techniques, such as meditating and performing yoga, decrease the recurrence of headache. Sumatriptan is a serotonin receptor antagonist that is effective in relieving migraine headaches. Lithium is a prophylactic drug used to treat cluster headaches. Prescribed muscle relaxants treat patients with tension-type headaches.

When performing a physical examination of a patient with Parkinson's disease, which associated clinical manifestations would the nurse likely identify? Select all that apply. nystagmus patchy blindness drooling of saliva decreased arm swing shuffling, propulsive gait

drooling of saliva decreased arm swing shuffling, propulsive gait The patient may manifest drooling of saliva, shuffling, propulsive gait, and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia. Parkinson's disease does not have clinical manifestations of patchy blindness (migraine headaches) or nystagmus.

Which factors lead to a higher risk of accidents or injuries in older adults? Select all that apply. decreased weight neurologic impairment decreased visual acuity increased muscle strength changes in gait and balance

neurologic impairment decreased visual acuity changes in gait and balance Many factors increase the risk for falls, including neurologic impairment (e.g., stroke, Parkinson's disease), decreased visual acuity, and changes in gait and balance. Decreased weight does not put a patient at risk for accidents. Decreased muscle strength, not increased muscle strength, puts a patient at risk for accidents.

Which information would the nurse include when teaching a patient with multiple sclerosis about the advantages of exercise during remission? Select all that apply. Decreases spasticity Increases coordination Helps to regain bladder control Delays the demyelination process Retrains unaffected muscles to substitute for impaired ones

Decreases spasticity Increases coordination Retrains unaffected muscles to substitute for impaired ones Encourage patients with multiple sclerosis in remission to exercise. Regular exercise can help to decrease spasticity, increase coordination, and retrain unaffected muscles to substitute for the impaired ones. The exercise does not help to regain bladder control or delay the demyelination process.

Which diagnostic test would the nurse anticipate for a patient with progressive weakness suspected of having multiple sclerosis? Positron emission tomography (PET) scan Complete blood count (CBC) Electroencephalogram (EEG) Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI) An MRI of the brain and spinal cord can show plaques, inflammation, atrophy, and tissue breakdown consistent with multiple sclerosis. A PET scan, CBC, and EEG can be used to diagnose seizure disorders.

For the patient taken to the hospital after a seizure, which characteristic pattern reported by the patient's caregiver would the nurse associate with those of a tonic-clonic seizure? Stiffening of the body for 20 seconds, followed by jerking of the extremities for 40 seconds Jerking of the extremities for 20 seconds, followed by stiffening of the body for 40 seconds Stiffening of the body for 30 seconds, followed by jerking of the extremities for 10 seconds Jerking of the extremities for 20 seconds, followed by stiffening of the body for 10 seconds

Stiffening of the body for 20 seconds, followed by jerking of the extremities for 40 seconds Loss of consciousness, followed by stiffening of the body for 20 seconds (10 to 20 seconds) and jerking of the extremities for 40 seconds (30 to 40 seconds) are features of tonic-clonic seizures. Jerking of the extremities for 20 seconds, followed by stiffening of the body for 40 seconds may not be associated with tonic-clonic seizures. Tonic-clonic seizures do not include stiffening of the body for 30 seconds, followed by jerking of the extremities for 10 seconds. Similarly, jerking of the extremities for 20 seconds, followed by stiffening of the body for 10 seconds is not with a characteristic of tonic-clonic seizures.

Which explanation would the nurse provide the patient who asked why he or she is on 100% oxygen for cluster headaches? The oxygen assists in increasing the release of glutamate in your brain. The administration of 100% oxygen increases your synthesis of serotonin. Acetylcholine secretion decreases with higher oxygenation saturation levels. Your dopamine levels are high, and the oxygen decreases dopamine secretion.

The administration of 100% oxygen increases your synthesis of serotonin. Oxygen treats acute cluster headaches by causing vasoconstriction, which facilitates the synthesis of serotonin. An increased release of glutamate causes amyotrophic lateral sclerosis. Dopamine deficiency causes Parkinson's disease. Decreased acetylcholine is a clinical manifestation of myasthenia gravis.

For the patient with Parkinson's disease who has difficulty swallowing, which intervention would the nurse initially include in the patient's plan of care? Arrange for someone to feed the patient. Provide the patient with semisolid or soft foods. Encourage the patient to drink fluids with meals. Place food into the unaffected side of the patient's mouth.

Provide the patient with semisolid or soft foods. In Parkinson's disease, the patient may have poor control of the tongue, increasing the risk for aspiration. Semisolid food without lumps and thickened liquids stick together, allowing the tongue to direct the food bolus to the back of the mouth. Encourage the patient to self-feed to maintain independence and function. Clear fluids with meals at any time may present a risk of aspiration if there is difficulty swallowing. Parkinson's disease likely affects the tongue and entire mouth, so placing food into the unaffected side of the patient's mouth is not an appropriate choice.

For the patient receiving initial medications for treatment of multiple sclerosis, which medication would the nurse associate with the patient's reports of flu-like symptoms, depressed feelings, and frequent thoughts of committing suicide? β-1a interferon (Rebif) Natalizumab (Tysabri) Mitoxantrone (Novantrone) Dalfampridine (Ampyra)

β-1a interferon (Rebif) β-interferon is an immunomodulator prescribed in the initial treatment of multiple sclerosis and known to cause flu-like symptoms, depression, and suicidal ideations. Natalizumab treats patients with active and aggressive forms of multiple sclerosis, and this drug is not part of initial treatment. The major risk factor associated with this drug therapy is progressive multifocal leukoencephalopathy. Mitoxantrone treats patients with active and aggressive forms of multiple sclerosis, not in the initial treatment. The risk factors associated with this drug are cardiotoxicity, leukemia, and infertility. Dalfampridine improves walking speed.

Which patient statements, made during the nurse's neurologic assessment, support the health care provider's diagnosis of cluster headache? Select all that apply. "My cheeks also ache during the headache." "My skin appears pale during the headache." "I feel like my limbs are moving during the headache." "I don't feel like sitting in one place during the headache." "I have a strong desire to eat ice cream and chocolates during the headache."

"My cheeks also ache during the headache." "My skin appears pale during the headache." "I don't feel like sitting in one place during the headache." A cluster headache has the manifestations of pain in the cheeks, gums, nose, and forehead. A cluster headache is also associated with restlessness and pallor (skin paleness). Feelings of limb movement and food cravings are clinical manifestations of migraine headache.

When teaching the clinical manifestations of cluster headaches to a group, which statement would the nurse include? "You may experience the pain for 4 to 72 hours." "When experiencing the pain, nausea is often present." "The pain may switch to the anterior side of your head." "The pain experienced in cluster headaches is unilateral."

"The pain experienced in cluster headaches is unilateral." Unilateral pain radiating up or down the eye is a characteristic of a cluster headache. Migraine headaches last for 4 to 72 hours and are associated with nausea. A migraine headache migrates towards the anterior portion of the head.

A severe headache associated with neck stiffness and sensitivity to sounds is a clinical manifestation of a tension-type headache. Acetaminophen is a nonsteroidal antiinflammatory drug effective in relieving a tension-type headache. Dexamethasone is a corticosteroid used to treat migraine headache. Dihydroergotamine and ergotamine tartrate are alpha-adrenergic blockers used to treat migraine headache. Polycythemia vera A cluster headache A migraine headache A hemorrhagic stroke

A migraine headache Although a headache may occur with any of these options, a migraine headache is the only one that has a throbbing headache with an aura (the photophobia). Headache from polycythemia vera is from erythrocytosis. The cluster headache pain is sharp and stabbing, and the headache with a hemorrhagic stroke has a sudden onset and is not recurrent.

Which prescribed medication would the nurse anticipate administering to the patient complaining of a severe headache, neck stiffness, and intensified pain upon exposure to sound? Acetaminophen (Tylenol) Dexamethasone (Dexasone) Dihydroergotamine (Migranal) Ergotamine tartrate (Ergomar)

Acetaminophen (Tylenol) A severe headache associated with neck stiffness and sensitivity to sounds is a clinical manifestation of a tension-type headache. Acetaminophen is a nonsteroidal antiinflammatory drug effective in relieving a tension-type headache. Dexamethasone is a corticosteroid used to treat migraine headache. Dihydroergotamine and ergotamine tartrate are alpha-adrenergic blockers used to treat migraine headache.

Which treatment option would the nurse associate with the patient who was received in the emergency department in an unconscious state, who has a routine prescription of gabapentin (Neurontin) for a history of epilepsy, and who is experiencing recurring seizures in rapid succession? Administer dextrose (D5W) IV Administer saline (NS 0.9%) IV Administer diazepam (Valium) IV Administer gabapentin (Neurontin) IV

Administer diazepam (Valium) IV Seizures that reoccur in rapid succession without the patient regaining consciousness are a characteristic feature of status epilepticus. It is a serious complication of epilepsy and occurs with any type of seizure. The most commonly used drug to treat status epilepticus is diazepam. Administer saline to patients with severe dehydration and electrolyte imbalance. Administer dextrose if the patient has seizures due to hypoglycemia. Gabapentin treats generalized seizures.

The patient with Parkinson's disease lost 35 pounds (15.9 kg) over the last two months, and a swallow study indicates ability to swallow without aspiration. Which intervention would the nurse discuss with the patient and spouse to improve nutritional intake? Include chewy foods so that the patient builds up the jaw muscles. Administer prescribed carbidopa/levodopa with a protein drink. Allow adequate time for the patient to eat each of six small meals. Encourage the patient to eat at least every two hours while awake.

Allow adequate time for the patient to eat each of six small meals. Allowing adequate time for the patient to eat each of six small meals will limit frustration and improve overall intake. Six small feedings may improve intake, but eating every two hours would exhaust the patient. Protein impairs the absorption of levodopa, so the best practice is to avoid large amounts of protein when administering carbidopa/levodopa. Foods should be easily chewable and dissected into small bites to increase the overall intake.

For the patient with multiple sclerosis, which action would the nurse classify as a priority intervention when developing the patient's plan of care? Refer the patient for genetic counseling. Teach the patient about medications used during acute exacerbations. Assist the patient in identifying the factors that precipitate exacerbations. Instruct the patient in the proper technique for self-administration of an enema.

Assist the patient in identifying the factors that precipitate exacerbations. The cause of multiple sclerosis is unknown, although fatigue, stress, or events such as pregnancy or acute illness can bring on an exacerbation. Identifying and avoiding such activities or factors may prevent exacerbations. Multiple sclerosis does not have a genetic link. Teaching the patient about medications and the proper technique for the self-administration of an enema is important but not as high of a priority as preventing exacerbations of the disease and complications.

Which identified clinical manifestation would the nurse associate with those exhibited with a cluster headache? Hemiparesis Photophobia Conjunctivitis Nuchal rigidity

Conjunctivitis Conjunctivitis is an integumentary manifestation associated with a cluster headache. Hemiparesis is a neurologic manifestation of a migraine headache. Photophobia is a clinical manifestation of a migraine. Nuchal rigidity is a musculoskeletal manifestation of a tension-type headache.

A relapsing-remitting initial course followed by the disease with or without relapses are characteristics of which type of multiple sclerosis? Relapsing-remitting Primary-progressive Progressive-relapsing Secondary-progressive

Secondary-progressive Secondary-progressive multiple sclerosis has a relapsing-remitting course that later becomes steadily progressive, with or without occasional relapses, minor remissions, and plateaus. Relapsing-remitting multiple sclerosis involves developing and resolving symptoms over a few weeks to months before the patient returns to the baseline. Primary-progressive multiple sclerosis involves steady and gradual neurologic dysfunction without remittance of the symptoms. Progressive-relapsing multiple sclerosis involves frequent relapses with a partial recovery, without the patient returning to the baseline.

Which caregiver's actions, implemented during the patient's acute seizure episode, indicates understanding of the home care measures taught prior to discharge? Select all that apply. Turning the patient to their side Loosening the patient's tight clothing Easing the patient to the floor, if seated Apply soft restraints to the patient's extremities. Immediately sending the patient to hospital after a single seizure

Turning the patient to their side Loosening the patient's tight clothing Easing the patient to the floor, if seated The caregiver should turn the patient to his or her side to protect the patient from injury. Loosening any restrictive clothing of the patient will ensure a patent airway. Similarly, if seated, easing the patient to the floor will help to protect the patient from injuries. It is not necessary to send a patient immediately to the hospital after a seizure, unless the seizure is prolonged, or another seizure immediately follows. Soft restraints are not applied to the patient's extremities during a seizure. The caregiver should clear the immediate area to prevent encountering objects that may cause harm or bruising.

"Drop attacks" are a characteristic of which type of seizure? tonic clonic atonic myoclonic

atonic A "drop attack" is a sudden fall without loss of consciousness. In atonic seizures, the patient suddenly falls to the ground due to paroxysmal loss of muscle tone. In tonic and clonic seizures, there may be loss of consciousness and the patient may fall. In a myoclonic seizure, the patient may fall to the ground due to excessive jerking of the extremities.

For which condition would the nurse administer 100% oxygen immediately? cluster headache MS Parkinsons disease migraine headache

cluster headache Acute treatment for a cluster headache includes administration of 100% oxygen through the nasal route. Drugs such as β-interferon, fingolimod, and natalizumab treat multiple sclerosis. Parkinson's disease is also a progressive neurodegenerative disease; drugs such as levodopa, ropinirole, and biperiden are effective in treating Parkinson's disease. Drugs such as sumatriptan, dexamethasone, and dihydroergotamine treat migraine headaches.

Which type of headache would the nurse associate with the patient's report of the headache occurring "on the right side of my head, around my right eye, and having a sharp, penetrating type of pain"? cluster headaches migraine headaches tension-type headaches (TTH) medication overuse headache

cluster headache In a cluster headache, the pain focuses in and around one eye and is often described as sharp, penetrating, or burning pain. The description of a migraine headache is an intense pounding or throbbing pain involving one temple; this headache may also be bilateral. The description of a tension headache is a feeling of weight in or on the head or a band squeezing the head. A medication overuse headache is the overuse of a drug; it is often described as a new type of headache or marked worsening of a preexisting headache condition.

Which condition would the nurse anticipate integrating into the patient's plan of care when the patient reports swelling around one eye, gum pain, unilateral lacrimation, and nasal congestion after applying perfume? cluster headache MS parkinsons disease migraine headache

cluster headache Strong odors trigger a cluster headache and manifest in a severe headache, swelling around the eye, pain in the gums, and nasal congestion. Paralysis of the limbs, blurred vision, tinnitus, and ataxia are the clinical manifestations of multiple sclerosis. Tremors, rigidity, and bradykinesia are the clinical manifestations of Parkinson's disease. Unilateral and pulsatile headaches are the clinical manifestations of a migraine headache.

Which classic symptom of amyotrophic lateral sclerosis (ALS) would the nurse expect to identify when performing an assessment? dysuria dyspnea dysphagia dysreflexia

dysphagia Weakness of the muscles of the legs that progresses to weakness in the upper extremities, dysarthria (difficulty in speech), and dysphagia (difficulty swallowing) are all classic symptoms of ALS. Although dyspnea and dysuria may be present in later stages of ALS, they are not classic symptoms of the disease. Dysreflexia occurs in patients with spinal cord injuries and is a life-threatening, uninhibited response of the nervous system to a noxious stimulus and not applicable to ALS.

Which teaching will the nurse provide for a patient with systemic lupus erythematosus (SLE) who presents to the emergency room after a grand mal seizure? "Seizures are caused by epilepsy; this is not related to SLE." "Seizures are a common occurrence in SLE; this is nothing to worry about." "Seizures are a common occurrence in SLE but can ideally be managed with oral medications." "Seizures are extremely rare in patients with SLE; the patient will need a further workup to determine the cause of the seizure."

"Seizures are a common occurrence in SLE but can ideally be managed with oral medications." Seizures occur in as many as 15% of patients with SLE by the time of diagnosis and are generally controlled with corticosteroids or antiseizure drugs. Seizures have a multitude of causes, including but not limited to epilepsy and latent effects of SLE. Seizures can represent a life-threatening insult and should be closely monitored. Seizures will indicate a further workup but are common with SLE.

Which patient complaint would indicate that the individual may be experiencing clinical manifestations of a cluster headache? "This pain is followed by severe nausea." "The pain lasts for longer than eight hours." "You don't understand, the pain is constant." "The pain wakes me up and disturbs my sleep at night."

"The pain wakes me up and disturbs my sleep at night." Cluster headaches usually occur at night and cause sleep disturbances. Therefore the patient's complaint about sleep-disturbing pain is a sign of a cluster headache. Constant pain is a characteristic of tension-type headaches. Migraine headaches are associated with nausea and vomiting; they usually exist for 4 to 72 hours.

For the patient with myasthenia gravis, which factors experienced in the patient's current life led to development of respiratory failure and a myasthenic crisis, requiring admission? Select all that apply. Attended the funeral of a family member earlier in week Took an antibiotic prescribed for a urinary tract infection Was diagnosed with urinary tract infection previous week Omitted pyridostigmine (Mestinon) on the previous day Consistently took prescribed corticosteroid every other day Laid down for a nap in a personal recliner after the noon meal each day

Attended the funeral of a family member earlier in week Took an antibiotic prescribed for a urinary tract infection Was diagnosed with urinary tract infection previous week Omitted pyridostigmine (Mestinon) on the previous day Myasthenia gravis is an autoimmune disease in which destruction of acetylcholine receptors occurs at the neuromuscular junction. Patients experience muscular weakness that improves with rest. A myasthenia crisis is an acute exacerbation of muscle weakness that often involves the respiratory muscles. Precipitation of exacerbations and crises occurs from many factors including infection (patient's urinary tract infection), emotional stress (funeral of family member), reaction to medications (antibiotic prescribed for urinary tract infection), and inadequate anticholinesterase medications. Pyridostigmine is an anticholinesterase medication that prolongs acetylcholine present in the neuromuscular junction to improve muscle strength. Taking corticosteroid medications as prescribed suppresses immunity to decrease the myasthenic effect of muscular weakness. Lying down for a nap in a personal recliner each day after the noon meal promotes rest.

For the patient receiving emergency treatment for continuous muscle contractions and loss of consciousness secondary to head trauma, which medications would the nurse anticipate administering? Select all that apply. Phenytoin (Dilantin) Zonisamide (Zonegran) Clonazepam (Klonopin) Ethosuximide (Zarontin) Carbamazepine (Tegretol)

Phenytoin (Dilantin) Carbamazepine (Tegretol) Characteristics of tonic-clonic seizures include continuous muscle contractions and loss of consciousness. The primary drugs used to treat tonic-clonic seizures are phenytoin and carbamazepine. Zonisamide, clonazepam, and ethosuximide are the drugs used to treat absence and myoclonic seizures.

Which prescribed IV injection would the nurse administer first for the patient experiencing status epilepticus? Diazepam (Valium) IV Phenytoin (Dilantin) IV Vecuronium (Norcuron) IV Vecuronium (Norcuron) IV

Diazepam (Valium) IV Diazepam administered as an IV push is one of the drugs of choice for a patient experiencing status epilepticus. Diazepam is a rapid-acting benzodiazepine but has a short duration, so follow diazepam with a longer-acting anticonvulsant medication. Vecuronium is a paralyzing agent and is not used to treat status epilepticus. Phenytoin is a long-acting anticonvulsant medication commonly administered after a rapid-acting benzodiazepine (such as diazepam) to help to stop a seizure and prevent further seizures. A patient experiencing extended episodes of status epilepticus may be at risk for dehydration, but prescribers do not consider lactated Ringer's IV fluids as an immediate intervention for rehydration.

Which information would the nurse provide the caregiver of a patient with acute seizures regarding actions to implement if another seizure occurs at home? Select all that apply. Ease the patient to the floor. Loosen constrictive clothes. Restrain the patient to a bed. Protect the patient from any injury. Bring the patient to the hospital immediately.

Ease the patient to the floor. Loosen constrictive clothes. Protect the patient from any injury. During an acute seizure, the most important thing is to ease the patient to the floor, if seated, and loosen constrictive clothing. Protect the patient from any potential injury. The chances of injury are higher if restraining the patient. It is not necessary to bring the patient to the hospital immediately. Once the seizures have stopped and the patient becomes stable, then transport the patient to the hospital.

Which information would the nurse provide the concerned parents of a child recently diagnosed with typical absence seizures? Select all that apply. A seizure is associated with loss of postural tone. The child will usually seem confused after a seizure. Brief staring spells are a characteristic of the seizure. Flashing lights usually precipitate this type of seizure activity. The occurrence of seizures usually subsides during adolescence.

Flashing lights usually precipitate this type of seizure activity. The occurrence of seizures usually subsides during adolescence .Brief staring spells are a characteristic of the seizure. The typical absence seizure usually occurs in childhood only, and the occurrences subside in adolescence. Brief staring spells that last for only a few seconds are a characteristic of the seizure. Flashing lights tend to precipitate a seizure. The child may not have loss of postural tone and may not experience confusion after a seizure.

Which extracranial condition would the nurse associate with a patient's seizures? migraine meningitis brain tumor hypertension

HTN Hypertension is an extracranial condition associated with seizures. Migraines, brain tumors, and meningitis are all intracranial conditions that can be associated with seizures.

For the patient reporting difficulty with eye and eyelid movement, chewing, swallowing, speaking, and breathing, which diagnostic findings would the nurse associate with myasthenia gravis? Select all that apply. Alteration of one copy of gene in DNA testing Improved muscle contractibility during the Tensilon test Presence of TRAP: tremor, rigidity, akinesia, and postural instability Decreased response to repeated stimulation of hand muscles during electromyography (EMG) test Increased immunoglobulin G levels in the cerebrospinal fluid (CSF) during CSF analysis test

Improved muscle contractibility during the Tensilon test Decreased response to repeated stimulation of hand muscles during electromyography (EMG) test Patients with myasthenia gravis experience improved muscle contractibility after IV administration of the anticholinesterase agent edrophonium chloride. This test aids in diagnosis of myasthenia gravis. EMG testing may show a decreased response to repeated stimulation of muscles in the hands, which would indicate muscle fatigue. Single-fiber EMG is a confirmative test for myasthenia gravis. The alteration of one copy of a gene in a DNA test is a diagnostic test for Huntington's disease, a genetically transmitted autosomal dominant disorder. The presence of TRAP is classic of Parkinson's disease and includes tremor, rigidity, akinesia, and postural instability, and is a confirmed diagnostic test for Parkinson's disease. Increased immunoglobulin G levels in the cerebrospinal fluid during CSF analysis test confirms multiple sclerosis, not myasthenia gravis.

For the patient with Parkinson's disease, which dietary adjustments would the nurse include in the plan of care to prevent malnutrition and constipation? Select all that apply. Cut food into bite-size pieces. Serve hot foods on a warmed plate. Include whole grains and fruits in the diet. Include plenty of food items high in protein. Provide three large meals rather than six small meals.

Include whole grains and fruits in the diet. Cut food into bite-size pieces. Serve hot foods on a warmed plate. Patients with Parkinson's disease are predisposed to malnutrition and constipation, owing to inadequate food intake caused by difficulty in chewing and swallowing. To promote adequate nutrition, the nurse should include whole grains and fruits in the diet, which will prevent constipation. Cut food into bite-size pieces so chewing and swallowing are easy. Serving hot foods on a warmed plate makes the food more appealing. Limit food items high in protein because they can interfere with the absorption of carbidopa-levodopa, the most common drug used in the treatment of Parkinson's disease. Six small meals, rather than three large meals, would be less exhausting for the patients.

When a patient's clinical manifestations include visual disturbances and seizures, which area of the brain would the nurse identify as the most likely location of the diagnosed brain tumor? Subcortical Parietal lobe Occipital lobe Temporal lobe

Occipital lobe Manifestations of tumors in the occipital lobe include vision disturbances and seizures. Manifestations of tumors in the subcortical region include hemiplegia; other symptoms may depend on area of infiltration. Tumors in the parietal lobe present with speech disturbance (if the tumor is in the dominant hemisphere), dystopia, spatial disorders, and unilateral neglect. Tumors in the temporal lobe present with few symptoms and few instances of seizures and dysphagia.

Which specific patient assessments would the nurse perform immediately after a status epilepticus event subsides? Select all that apply. Pain Oxygenation Apical heart rate Oral body temperature Respiratory rate and pattern

Oxygenation Oral body temperature Respiratory rate and pattern Status epilepticus may cause a patient's hypoxia, hyperthermia, and ventilatory insufficiency. Therefore, the nurse should assess the patient's oxygenation level, oral body temperature, and respiratory rate and pattern. Status epilepticus is one of the complications of all types of seizures. The patient's pain level is not essential at this time. Tachycardia is the clinical sign of tonic-clonic seizures, so the nurse need not focus on the apical heart rate. However, the nurse may monitor the heart rate to check for any improvement of the patient's overall health.

Which nursing strategy should be implemented when caring for a patient who has Parkinson's disease and is at risk of falling? Obtain an order for physical restraints to be used. Perform hourly rounds to assess the patient's needs. Encourage the patient to stay in bed to nap frequently. Ask family members to stay with the patient at all times.

Perform hourly rounds to assess the patient's needs. Safety is a primary concern when caring for an older adult who has a high risk for falls. The nurse should perform hourly rounds to ensure that the patient's basic physiologic needs are being met. Physical restraints should be used as a last resort. Families can sit with the patient; however, there may not be family available, or family they may not be available at all times. Encouraging the patient to stay in bed decreases the patient's mobility and is not necessary.

Which criterion would the nurse associate with the health care provider's diagnosis of Parkinson's disease (PD)? Select all that apply. Decreased serum dopamine levels Tumor present in the thymus gland Positive response to antiparkinsonian medications MRI shows areas of plaque on cranial nerves Presence of two of the three classic features: rigidity, bradykinesia, and tremor

Positive response to antiparkinsonian medications Presence of two of the three classic features: rigidity, bradykinesia, and tremor Presently, there is no specific test to diagnose PD. When the patient demonstrates two of the three classic signs: rigidity (increased resistance to passive motion as a cogwheel), bradykinesia (slowed and loss of automatic coordinated movement), and tremor (a tremor that is more severe at rest and pill-rolling hand tremor), the diagnosis occurs. Confirmation of the PD diagnosis is a positive response to medications used to treat the disease, such as carbidopa/levodopa. The cause of PD is decreased dopamine levels in the brain and inability to measure dopamine in the serum. Tumors of the thymus gland are associated with myasthenia gravis. MRI of patients with multiple sclerosis indicate areas of plaque development.

During an acute exacerbation of the patient's multiple sclerosis, which interventions would the nurse implement? Select all that apply. Assist the patient with the grieving process. Prevent the complication of pressure ulcers. Prevent the complication of urinary tract infections. Teach the patient to build a general resistance to illness. Teach the patient to maintain a good balance between exercise and rest.

Prevent the complication of pressure ulcers.Prevent the complication of urinary tract infections. A patient experiencing an acute exacerbation of multiple sclerosis may be immobile and confined to bed. The first nursing interventions in this phase target the prevention of major complications associated with immobility. Pressure ulcers may occur due to the immobility of the patient while confined to the bed. Implement immediate care to prevent this. Urinary tract infections are also common due to the stagnation of urine. Assisting the patient with the grieving process is an important intervention during the diagnostic phase of multiple sclerosis but is not applicable to a patient with an acute exacerbation of the disease. Teaching the patient to build general resistance to illness is a general intervention for a patient suffering from multiple sclerosis. Teaching the patient to maintain a good balance between exercise and rest is a general intervention for a patient with multiple sclerosis but is not applicable for patients who are immobile.

Which intervention would the nurse implement when a patient experiences a generalized tonic-clonic seizure? Restrain the patient's arms and legs. Control head movements of the patient. Protect the patient's head and extremities. Insert a tongue blade between the patient's teeth.

Protect the patient's head and extremities. Staying with the patient to provide protection of the head and extremities is the most important nursing care activity for a patient experiencing a generalized tonic/clonic seizure. Attempting to restrain or control the jerking movement of the head and extremities during a seizure may cause further injury and even fracture bones. Do not restrain or control body parts. Use of a tongue blade is not acceptable in current practice because insertion once the seizure begins is difficult and the patient may bite through the tongue blade and aspirate.

Regarding the patient with Parkinson's disease (PD) who recently entered a long-term care facility, which action would the health care team implement to promote adequate nutrition for this patient? Provide multivitamins with each meal. Provide a diet low in complex carbohydrates and high in protein. Provide small, frequent meals throughout the day that are easy to chew and swallow. Provide the patient with minced or pureed diet, high in potassium and low in sodium.

Provide small, frequent meals throughout the day that are easy to chew and swallow. Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal; and the patient's vitamin intake, along with protein intake, will be monitored to prevent contraindications with medications. It is premature to introduce a minced or pureed diet at this time, and a low-carbohydrate diet is not indicated.

For patients with amyotrophic lateral sclerosis (ALS), which treatment goal focuses on preventing a common cause of death in patients with ALS? Reduced fat intake Reduced risk of aspiration Decreased injury related to falls Decreased pain secondary to muscle weakness

Reduced risk of aspiration Reducing the risk of aspiration can help to prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients.

Which interventions would the nurse implement immediately for the patient experiencing generalized tonic-clonic seizures due to hypoxia? Select all that apply. Remove restrictive clothes. Ensure the presence of a patent airway. Administer IV dextrose (D5W). Force the airway between clenched teeth. Administer IV phenytoin (Dilantin).

Remove restrictive clothes. Ensure the presence of a patent airway. Hypoxia is a metabolic disturbance that can cause seizures. In this case, treat the underlying cause first to control the seizure. Manage hypoxia by ensuring a patent airway and removing tight clothes. Administer dextrose in patients with hypoglycemia. Administer phenytoin after treating the underlying cause. The nurse should never force the airway between the patient's clenched teeth.

When reviewing the admission assessment data of a hospitalized pediatric patient, which findings would the nurse associate with the clinical manifestations of typical absence seizures? Select all that apply. brain injury daydreaming hyperventilation loss of consciousness EEG results

daydreaming hyperventilation EEG results Patients with typical absence seizures display behaviors associated with daydreaming. Hyperventilation is a precipitating factor for a typical absence seizure. Electroencephalogram (EEG) results demonstrate a 3-Hz spike-and-wave pattern and are the characteristic feature of a typical absence seizure. Tonic-clonic seizures occur in children in whom birth injury is one of the primary causes of seizures. Characteristics of typical and atypical absence seizures include loss of consciousness with different durations.

For the patient with Parkinson's disease who is taking levodopa with carbidopa (Sinemet), the nurse would monitor the potential development of which side effect(s)? Select all that apply. dizziness dyskinesia severe headache involuntary eyelid movement severe nausea and vomiting

dyskinesia involuntary eyelid movement severe nausea and vomiting Sinemet is a combination of levodopa and carbidopa and is prescribed to patients suffering from parkinsonism. The drug has few side effects. These side effects include dyskinesia due to increased dopamine availability. Severe nausea and vomiting are other important side effects because the dopaminergic pathway is the major pathway involved in emesis. Increased dopamine levels in the body may trigger the sensation of nausea and vomiting. Involuntary eyelid movements are due to the increased levels of the neurotransmitter dopamine in the body. Dizziness or fainting, due to orthostatic hypotension, is a side effect of the drug bromocriptine. A severe headache is also a side effect of bromocriptine.

Which seizure activity would the nurse associate with a patient's jerky muscle movements of the extremities, as well as bowel and bladder incontinence during the event? aura seizures postical seizure generalized seizures simple partial seizures

generalised seizures In a generalized, or grand mal, seizure, the patient may experience incontinence along with jerking, or tonic-clonic, movements of the entire body. An aura is an individualized, subjective auditory, visual, olfactory, or taste hallucination that may precede a seizure. Postictal is the period of recovery after a seizure and may include confusion and sedation. Potentially isolated to one side of the brain, a simple partial seizure remains partial or focal in nature, or it may spread to involve the entire brain, culminating in a generalized tonic-clonic seizure. Simple partial seizures generally do not involve loss of consciousness and rarely last more than one minute.

If a patient has Parkinson's disease, which patient reaction would the nurse expect when performing a pull test by standing behind the patient and giving a tug backward on the patient's shoulders? loses balance and sits down loses balance and falls foreward loses balance and falls backwards loses balance and becomes unconscious

loses balance and falls backwards In a pull test, when the examiner stands behind the patient and gives a tug backward on the shoulder, the patient loses balance and falls backward. This reaction indicates postural instability, a common feature in Parkinson's disease. Sitting down, falling forward, or becoming unconscious after losing balance is not indicative of postural instability related to Parkinson's disease.

Which seizure disorder typically occurs in children and rarely continues beyond adolescence? focal seizures tonic-clonic seizures psychogenic seizures typical absence seizures

typical absence seizures Typical absence seizures occur typically in children and rarely continuing beyond adolescence. A psychogenic seizure may be mistaken for epilepsy. A tonic-clonic seizure is the most common generalized seizure. Focal seizures are a major class of seizures. Psychogenic, tonic-clonic, and focal seizures can occur in patients of all ages.

For the patient voicing complaints of pain on the left side of the head, nausea, vomiting, and sensitivity, which potential condition would the nurse associate with the prescriber's treatment of corticosteroids? migraine MS cluster headache parkinson's

migraine Unilateral headache proceeded by nausea, vomiting, and photophobia are the clinical manifestations of migraine. Prescribers use drugs like corticosteroids in the treatment of migraine headaches. Therefore the nurse anticipates that the patient has a migraine. Paralysis of the limbs, blurred vision, tinnitus, and ataxia are the clinical manifestations of multiple sclerosis. Stabbing headache, swelling around the eye, nasal congestion, and flushing or pallor are the clinical manifestations of cluster headache. The manifestations of Parkinson's disease are rigidity, tremors, and bradykinesia.

Which condition is consistent with excessive daytime sleepiness and a decreased dopamine level? narcolepsy jet lag disorder alzheimer's disease parkinson's disease

parkinson's disease Degeneration of dopamine neurons in the substantia nigra occurs in patients with Parkinson's disease; this leads to excessive daytime sleepiness. In narcolepsy syndrome, there is a decreased level of orexin. It results in an uncontrollable urge to sleep. Jet lag occurs when a person travels across multiple time zones. In the case of Alzheimer's disease, there is loss of cholinergic neurons in the basal forebrain, which causes sleep disturbances.

Which neurodegenerative disorder has the characteristics of rigidity and bradykinesia? MS parkinson's disease lou gehrigs disease huntingtons disease

parkinsons disease Parkinson's disease is a chronic, progressive neurodegenerative disorder characterized by an increased muscle tone (known as rigidity), slowness in the initiation and execution of movement (known as bradykinesia), tremors, and gait disturbances. Multiple sclerosis is a chronic progressive degenerative disorder of the central nervous system characterized by progressive, chronic demyelination of nerve fibers of the spinal cord and brain. Lou Gehrig's disease is a rare progressive neurologic disorder involving degeneration of motor neurons in the spinal cord and brain; characteristics include limb weakness, dysarthria, and dysphagia. Huntington's disease is a genetically transmitted, autosomal dominant disorder characterized by chorea movements and cognitive and psychiatric disorders.

When evaluating the presence of an initial symptom of Parkinson's disease, which clinical manifestation would the nurse evaluate? akinesia aspiration forgetfullness pill-rolling tremors

pill-rolling tremors Early symptoms of Parkinson's disease include coarse resting tremors of the fingers and thumb, also known as pill-rolling movements. Akinesia (complete or partial loss of muscle movement), aspiration, and mental deterioration occur later in the disease process.

When planning the care for a patient with multiple sclerosis who has an exacerbation of sensory deficits, for which patient problem would the nurse develop nursing interventions? risk for injury acute confusion fluid volume defecit ineffective thermoregulation

risk for injury Multiple sclerosis usually exhibits itself on one side more than the other. Therefore the gait is unsteady, so there is an increase in the patient's fall risks. Acute confusion may be a manifestation experienced by some patients later in the multiple sclerosis disease process. Deficient fluid volume and ineffective thermoregulation are not characteristics of multiple sclerosis. Visual disturbances and muscle spasticity may also contribute to the patient's potential risk for injury.

Which clinical manifestation is exclusive to a complex focal seizure? jerking of the limbs smacking of the lips loss of consciousness increased muscle tone

smacking of the lips Smacking of the lips is the characteristic feature seen only in complex focal seizures. Jerking of the limbs, loss of consciousness, and increased muscle tone occur in all other types of seizures. Sometimes focal seizures may spread across the entire brain and culminate in a generalized tonic-clonic seizure. This spread results in symptoms such as jerking of the limbs, loss of consciousness, increased muscle tone, and lip smacking.

Which disorder would the nurse associate with a patient's seizure lasting longer than five minutes and occurring in rapid succession without a return to consciousness between seizures? epilepsy tonic seizure absence seizure status epilepticus

status epilepticus Status epilepticus is a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. Epilepsy is a disorder marked by a continuing predisposition to seizures with neurobiologic, cognitive, psychologic, and social consequences. The characteristics of an absence seizure is a brief staring spell lasting less than 10 seconds. A tonic seizure involves a sudden increase in tone of the exterior muscles that contribute to sudden stiff movements, lasting 20 seconds or less.

For the patient who sustained a head trauma, which type of seizure might he or she experience while on a ventilator and receiving sedation medications in the intensive care unit? atonic seizure myoclonic seizure subclinical seizure tonic-clonic seizure

subclinical seizure In subclinical seizures, the sedated patient experiences seizures, but external signs are not visible due to the sedative medication. In atonic seizures, the external signs like paroxysmal loss of muscle tone are visible. In myoclonic seizures, the patient may have sudden and excessive jerks of the body. In tonic-clonic seizures, the skin feels warm and has visible symptoms of cyanosis.

Which term would the nurse use to document a patient who suddenly lost consciousness, stiffened for about 15 seconds, and then developed a jerking motion of the extremities? focal seizure tonic-clonic seizure psychogenic seizure typical absence seizure

tonic-clonic seizure Tonic-clonic seizures are the most common generalized seizures and are characterized by a loss of consciousness, stiffening of the body for 10 to 20 seconds, and subsequent jerking of the extremities. Focal seizures are partial seizures. Focal seizures begin in one hemisphere of the brain in a specific region of the cortex. They produce signs and symptoms related to the function of the area of the brain involved. Psychogenic seizures are pseudoseizures also. They are psychiatric in origin and closely resemble epileptic seizures. A patient with psychogenic seizures has a history of emotional abuse, physical neglect, or a specific traumatic episode. Typical absence seizures are generalized seizures called petit mal seizures and usually occur in children. The clinical manifestation is a brief staring spell that lasts for a few seconds.

Which diagnostic criterion would the nurse include for migraine headaches when explaining the difference between a migraine headache and a tension-type headache (TTH)? unilateral pain pain that does not throb movement does not affect its severity photophobia or phonophobia, but not both

unilateral pain Migraine headaches have at least two of the following characteristics: unilateral, throbbing, aggravated by movement, moderate to severe intensity. Migraine headaches also have at least one of the following characteristics: nausea/vomiting, photophobia, and phonophobia. TTHs have at least two of the following characteristics: bilateral, nonthrobbing, movement does not affect its severity, mild to moderate intensity. TTHs also have at least one of the following characteristics: no nausea/vomiting, photophobia or phonophobia but not both.