Unit 10 Mixed bag (Peripheral neuropathy, FTT, GFTT, Cerebral Palsy)

*Possible Exam question* A patient with geriatric failure to thrive (GFTT) asks why vitamins D and B12 and folate were prescribed. Which response should the nurse provide? A) "These vitamins help your body better absorb the calories you are taking in." B) "These vitamins will help you feel strong." C) "These vitamins help overall health." D) "These vitamins prevent depression."

A) "These vitamins help your body better absorb the calories you are taking in." Rationale: Although there are no medications indicated for primary treatment of FTT, vitamins D and B12 and folate provide nutritional supplementation to treat deficiencies. The other options are incorrect responses to address the patient's question.

A female 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? A) "You may have difficulty believing this, but the paralysis caused by this disease is temporary." B) "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." C) "It must be hard to accept the permanency of your paralysis." D) "You'll first regain use of your legs and then your arms

A) "You may have difficulty believing this, but the paralysis caused by this disease is temporary." Rationale: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

An older adult patient with geriatric failure to thrive (GFTT) has a bowel obstruction.Which collaborative intervention should the nurse anticipate for this patient? A) Surgical treatment B) Physical therapy C) Dietitian consultation D) Pharmacologic therapy

A) Surgical treatment Rationale: Surgery is indicated to relieve the medical condition contributing to GFTT. Although medications may help, they will not relieve the bowel obstruction. Physical therapy and a dietary consult may be necessary after the surgery to prevent a future obstruction.

The nurse is caring for a patient with Parkinson disease.Which reason should the nurse identify that increases this patient's risk for developing geriatric failure to thrive (GFTT)? A)Feeding difficulties B)Substance abuse C) Decrease in cognitive function D) Increased desire to exercise

A)Feeding difficulties Rationale: Parkinson disease (PD) is a neurocognitive disorder that can cause dysphagia and tremors that make it difficult to get food into the mouth and therefore may increase the person's susceptibility to GFTT. Exercise may become difficult for a person with PD. PD also contributes to a decrease in cognitive function. Substance abuse is a risk factor for FTT but seldom related to PD.

A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client's behavior. A) Is disoriented to person, place, and time B) Affect is flat, with periods of emotional lability C) Cannot recall what was eaten for breakfast today D) Demonstrate inability to add and subtract; doesn't know who is president

B) Affect is flat, with periods of emotional lability Rationale: The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus.

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid? A) Head mildline B) Head turned to the side C) Neck in neutral position D) HOB elevated 30-45 degrees

B) Head turned to the side Rationale: The head of the client with increased intracranial pressure should be positioned so the head is in a neutral midline position. The nurse should avoid flexing or extending the client's neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure down.

The nurse is teaching the mother on how to take meticulous care of her child who is experiencing failure to thrive. The mother would not be correct in saying: A) "I will feed the child slowly and carefully in a quiet environment." B) "I will burp the child frequently during and at the end of each feeding." C) "I will talk to the child in a loud and booming way so that he could be stimulated and respond accordingly." D) "I will carefully document food intake with caloric intake and strict intake and output records."

C) "I will talk to the child in a loud and booming way so that he could be stimulated and respond accordingly." Rationale: Talk to the child in a warm, soothing tone to provide sensory stimulation. All other options are correct interventions for a child who has failure to thrive.

A 7 month old child has been diagnosed with CP. Which of the following signs/symptoms would the nurse assess as consistent with the diagnosis? A) Circumoral cyanosis B) Pigeon chest C) Positive grasp reflex D) Harlequin sign

C) Positive grasp reflex Rationale: Positive grasp reflex would be consistent with the diagnosis. : In healthy babies, the neonatal grasp reflex begins to fade at about 3 months of age and is replaced by a voluntary grasp by about 5 months of age. A grasp reflex that does not fade is consistent with a diagnosis of CP. Pigeon chest is unrelated to a diagnosis of CP. Harlequin sign is unrelated to a diagnosis of CP. Circumoral cyanosis is unrelated to a diagnosis of CP.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: A) prevent respiratory alkalosis. B) lower arterial pH. C) promote carbon dioxide elimination. D) maintain partial pressure of arterial

C) Promote carbon dioxide elimination Rationale: The goal of treatment is to prevent acidemia by eliminating carbon dioxide. That is because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this case. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.

A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness? A) Giving client full control over care decisions and restricting visitors B) Providing positive feedback and encouraging active range of motion C) Providing information, giving positive feedback, and encouraging relaxation D) Providing intravenously administered sedatives, reducing distractions and limiting visitors

C) Providing information, giving positive feedback, and encouraging relaxation Rationale: The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

A patient with geriatric failure to thrive (GFTT) is scheduled for diagnostic testing.Which test should the nurse expect to be prescribed for this patient? A) Sedimentation rate B) Electrolytes C) Serum proteins D) Serotonin-norepinephrine reuptake

C) Serum proteins Rationale: Assessing serum proteins are appropriate for the patient with GFTT. Electrolytes and sedimentation rate are not indicated for this health problem. Serotonin-norepinephrine reuptake is an intervention for GFTT.

An 85-year-old patient is diagnosed with anorexia of aging.For which potential complication of geriatric failure to thrive (GTT) should the nurse plan care for this patient? A) Predisposition to cancer B) Development of anhedonia C) Experience of anxiety D) Increased susceptibility to illness

D) Increased susceptibility to illness Rationale: Anorexia in older adults can lead to an increased susceptibility to illnesses. Anorexia does not result in cancer. Anhedonia and increased anxiety may cause a decrease in appetite and lead to FTT.

The nurse assesses a baby who is not gaining weight, has poor eye contact, lacks anticipated stranger danger, and appears older than chronologial age. Which type of FTT should the nurse suspect in this baby? A) Geriatric B) Organic C) Feeding D) Inorganic

D) Inorganic Rationale: Infants with nonorganic FTT show delayed development without any physical cause. They are often malnourished and fail to gain weight and grow normally. Behavior may be apathetic and withdrawn, and the child may demonstrate poor eye contact and lack anticipated stranger danger. GFTT may occur when older adults have decline of physical functioning and decline of body weight. Organic FTT is caused by disease or congenital malfunctions. There is not a feeding FTT.

The nurse is providing care to a patient diagnosed with failure to thrive (FTT).The nurse anticipates which treatment to be prescribed? A) Beta blockers B) Proton pump inhibitors C) Formula feeding by gastric tube D) Nutritional supplements

D) Nutritional supplements Rationale: Treatment of FTT includes nutritional supplements. Formula feeding by gastric tube is not a typical treatment option for FTT. Medications are not used in the treatment of FTT.

Cerebral palsy (CP) may result from a variety of causes. It is now known that the most common cause of CP is A) Birth asphyxia B) neonatal diseases C) Cerebral trauma D) Prenatal brain abnormalities

D) Prenatal brain abnormalities

Female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has history of: A) Seizures or trauma to the brain B) Meningitis during the last 5 years C) Back injury or trauma to the spinal cord D) Respiratory or gastrointestinal infection during the previous month.

D) Respiratory or GI infection during the previous month Rationale: Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery