Prepu chapter 64

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

Assessing respiratory effort

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

A nurse is assessing a patient's risk for pressure ulcers using the Braden scale. Which area would the nurse address?

Moisture

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

Tensilon test

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

Providing supportive care

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain?

"I was brushing my teeth."

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.

Allow the patient adequate time to perform exercises Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas.

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

Headache and nuchal rigidity

Which intervention has the highest priority when providing skin care to a bedridden client?

Keeping the skin clean and dry without using harsh soaps

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

MS

A client is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The client has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the client now able to use?

Parallel bars

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

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

Specialty mattress

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

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 III

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.

The nurse is performing range-of-motion exercises. Which of the following best depicts dorsiflexion of the foot?

where the toes are brought closer to the shin

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 patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate?

"Keep your fluid intake to fewer than 2 liters per day."

A nurse is describing the concept of rehabilitation to a group of families who have members in need of these services. Which statement would the nurse include in the description?

"Rehabilitation focuses on the person's abilities."

The nurse is talking with the mother of a client who is diagnosed with a traumatic brain injury. The mother states that she has never seen the client lash out when frustrated or throw things across the room. Which instruction, made by the nurse, is most correct?

"The client may be experiencing a change in affect due to the brain injury."

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."

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 teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching?

"You'll need to take edrophonium (Tensilon) to treat the disease."

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision

A client admitted with meningitis is to receive Vancocin (vancomycin) 250 mg in 100 mL intravenously over 60 minutes twice a day. The IV tubing set is calibrated at 15 drops per/mL. At how many drops per minute will the nurse run this solution? Enter the correct number ONLY.

25

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 drops per minute

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

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.

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?

Antibodies are removed from the plasma.

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splints

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.

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

Atropine

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

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 is caring for a client who is documented to have orthostatic hypotension. The nurse anticipates finding which symptom upon assessment?

Dizziness

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.

Eating Toileting Bathing

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)

The nurse is caring for a client who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed?

Ensure that suction apparatus is set up at the bedside

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.

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?

Facial distortion and pain

Which is often the most disabling clinical manifestation of multiple sclerosis?

Fatigue

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.

While assessing a newly admitted client, the nurse identifies impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest?

Impaired physical mobility

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 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.

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

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 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?

Muscle weakness and hyporeflexia of the lower extremities

Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?

Polymerase chain reaction (PCR)

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 assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign

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 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

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

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

The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure?

Sensory perception

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

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission

A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?

Streptococcus pneumoniae

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 with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

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

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 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.

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

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

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.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients?

gag reflex

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room.

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 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 knees and hips

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

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

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours.

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.

Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply.

Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Interferon beta-1a (Rebif) Glatiramer acetate (Copaxone)

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.

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon)

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

Help the client perform range-of-motion (ROM) exercises every 8 hours.

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.