58 Neuro - Lippincotts
A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved: 1. Functional ability. 2. Emotional stress. 3. Alertness. 4. Appetite.
1 The goal of a pallidotomy is to improve functional ability for the pt with Parkinson's disease. This is a priority! The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the pt may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure.
A client with multiple sclerosis (MS) is receiving baclofen (Lioresal). The nurse determines that the drug is effective when it achieves which of the following? 1. Induces sleep. 2. Stimulates the client's appetite. 3. Relieves muscular spasticity. 4. Reduces the urine bacterial count.
3 Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms common in MS. Drowsiness is an adverse effect & driving should be avoided if the medication produces a sedative effect. Baclofen does NOT stimulate the appetite or reduce bacteria in the urine.
The nurse develops a teaching plan for a client newly diagnosed with Parkinson's disease. Which of the following topics that the nurse plans to discuss is the most important? 1. Maintaining a balanced nutritional diet. 2. Enhancing the immune system. 3. Maintaining a safe environment. 4. Engaging in diversional activity.
3. The primary focus is on maintaining a safe environment because the pt with Parkinson's disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the pt to fall or to have trouble stopping. The pt should maintain a balanced diet, enhance the immune system & enjoy diversional activities
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene? 1. Placing the client on the back with a small pillow under the head. 2. Keeping portable suctioning equipment at the bedside. 3. Opening the client's mouth with a padded tongue blade. 4. Cleaning the client's mouth and teeth with a toothbrush.
1. A helpless Pt should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat & mouth, minimizing the risk of aspiration. It may be necessary to suction the Pt if they aspirate Suction equipment should be nearby It is safe to use a padded tongue blade & the pt should receive oral care, including brushing with a toothbrush.
What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist? 1. To maintain joint flexibility. 2. To build muscle strength. 3. To improve muscle endurance. 4. To reduce ataxia.
1. The primary goal of physical therapy & nursing interventions is to maintain joint flexibility & muscle strength. Parkinson's disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or ↑ endurance. The ↓ in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to ↓ ataxia through physical therapy would NOT be effective.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because? 1. The rehabilitation plan will be guided by it. 2. Functional status before the stroke will help predict outcomes. 3. It will help the client recognize his physical limitations. 4. The client can be expected to regain much of his functioning.
1. The primary reason for the nursing assessment of a Pt's functional status before & after a stroke is to guide the plan. The assessment does not help to predict how far the rehabilitation team can help the Pt to recover from the residual effects of the stroke, only what plans can help a Pt who has moved from one functional level to another. The nursing assessment of the Pt's functional status is not a motivating factor.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20? 1. Head trauma. 2. Electrolyte imbalance. 3. Congenital defect. 4. Epilepsy.
1. Trauma is one of the primary causes of brain damage & seizure activity in adults Other common causes of seizure activity in adults include: - neoplasms - withdrawal from drugs & alcohol - vascular disease. Given the history of head injury, electrolyte imbalance is not the cause of the seizure. There is no information to indicate that the seizure is related to a congenital defect. Epilepsy is usually diagnosed in younger clients.
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used? 1. The client exhibits intolerance to many drugs. 2. The client experiences spontaneous remissions from time to time. 3. The client requires multiple drugs simultaneously. 4. The client endures long periods of exacerbation before the illness responds to a particular drug.
2 Evaluating drug effectiveness is difficult because a high % of ps with MS exhibit unpredictable episodes of remission, exacerbation & steady progress w/o apparent cause. Pts with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a particular drug. Multiple drug use is NOT what makes evaluation of drug effectiveness difficult.
The nurse is teaching a client about taking prophylactic warfarin sodium (Coumadin). Which statement indicates that the client understands how to take the drug? Select all that apply. 1. "The drug's action peaks in 2 hours." 2. "Maximum dosage is not achieved until 3 to 4 days after starting the medication." 3. "Effects of the drug continue for 4 to 5 days after discontinuing the medication." 4. "Protamine sulfate is the antidote for warfarin." 5. "I should have my blood levels tested periodically."
2, 3, 5. The maximum dosage of warfarin sodium (Coumadin) is not achieved until 3 -4 days after starting the medication & the effects of the drug continue for 4-5 days AFTER D/C the medication. The pt should have blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a PEAK action of 9 hrs *Vitamin K is the antidote for warfarin *Protamine sulfate is the antidote for heparin.
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply. 1. Restrict fluids to 1,000 mL/ 24 hours. 2. Drink 400 to 500 mL with each meal. 3. Drink fluids midmorning, midafternoon, and late afternoon. 4. Attempt to void at least every 2 hours. 5. Use intermittent catheterization as needed.
2,3,4,5 Maintaining urinary function in a pt with neurogenic bladder dysfunction from MS is an important goal. The pt should ideally drink 400-500 mL with each meal; 200 mL mid-morning, mid-afternoon, and late afternoon Attempt to void at least every 2 hrs to prevent infection & stone formation. The pt may need to catheterize herself to drain residual urine in the bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder training for night-time continence, the pt may restrict fluids for 1-2 hrs before going to bed. The pt should drink at least 2,000 mL/24 hours.
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which of the following strategies is not appropriate? 1. Maintaining an upright position. 2. Restricting the diet to liquids until swallowing improves. 3. Introducing foods on the unaffected side of the mouth. 4. Keeping distractions to a minimum.
2. A pt with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be THICK to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side allows the Pt to have better control over the food bolus. The Pt should concentrate on chewing & swallowing; therefore, distractions should be avoided.
When preparing to teach a client about phenytoin sodium (Dilantin) therapy, the nurse should urge the client not to stop the drug suddenly because: 1. Physical dependency on the drug develops over time. 2. Status epilepticus may develop. 3. A hypoglycemic reaction develops. 4. Heart block is likely to develop.
2. Anticonvulsant drug therapy should NEVER be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhythmic properties & discontinuation does not cause heart block.
For breakfast on the morning a client is to have an electroencephalogram (EEG), the client is served a soft-boiled egg, toast with butter and marmalade, orange juice, and coffee. Which of the following should the nurse do? 1. Remove all the food. 2. Remove the coffee. 3. Remove the toast, butter, and marmalade only. 4. Substitute vegetable juice for the orange juice.
2. Beverages containing caffeine, such as coffee, tea & cola drinks, are withheld before an EEG because of the stimulating effects of the caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee.
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication? 1. Speaking loudly. 2. Using a picture board. 3. Writing directions so client can read them. 4. Speaking in short sentences.
2. Expressive aphasia is a condition in which the pt understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the pt communicate with others in that the pt can point to objects or activities that he or she desires.
Which of the following should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin (Neurontin)? 1. Take all the medication until it is gone. 2. Notify the physician if vision changes occur. 3. Store gabapentin in the refrigerator. 4. Take gabapentin with an antacid to protect against ulcers.
2. Gabapentin (Neurontin) may impair vision. Changes in vision, concentration, or coordination should be reported to the physician. Gabapentin should NOT be stopped abruptly because of the potential for status epilepticus; this is a medication that MUST be tapered off. Gabapentin is to be stored at room temperature & out of direct light. It should NOT be taken with antacids.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response. 3. Bowel sounds. 4. Echocardiogram.
2. It is crucial to monitor the pupil size & pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hrs, when the primary concerns are cerebral hemorrhage & increased intracranial pressure. An echocardiogram is not needed for the pt with a thrombotic stroke w/o heart problems.
Which of the following is an initial sign of Parkinson's disease? 1. Rigidity. 2. Tremor. 3. Bradykinesia. 4. Akinesia.
2. The FIRST sign of Parkinson's disease is usually tremors. The pt commonly is the FIRST to notice this sign because the tremors may be minimal at first. Rigidity is the 2nd sign Brady-kinesia is the 3rd sign. Akinesia is a later stage of bradykinesia.
When communicating with a client who has aphasia, which of the following nursing interventions is not appropriate? 1. Present one thought at a time. 2. Encourage the client not to write messages. 3. Speak with normal volume. 4. Make use of gestures.
2. The nurse should encourage the pt to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time ↓ stimuli that may distract the pt, as does speaking in a normal volume & tone. The nurse should ask the pt to "show me" & should encourage the use of gestures to assist in getting the message across with minimal frustration & exhaustion for the pt.
Which statement by a client with a seizure disorder taking topiramate (Topamax) indicates the client has understood the nurse's instruction? 1. "I will take the medicine before going to bed." 2. "I will drink 6 to 8 glasses of water a day." 3. "I will eat plenty of fresh fruits." 4. "I will take the medicine with a meal or snack."
2. Toxic effects of topiramate (Topamax) include nephrolithiasis & pts are encouraged to drink 6-8 glasses of water a day to dilute the urine & flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does NOT have to be taken with meals.
The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors? 1. The tremors are probably psychological and can be controlled at will. 2. The tremors sometimes disappear with purposeful and voluntary movements. 3. The tremors disappear when the client's attention is diverted by some activity. 4. There is no explanation for the observation; it is probably a chance occurrence.
2. Voluntary & purposeful movements often temporarily ↓ or stop the tremors associated with Parkinson's disease. In some pts, however, tremors may ↑ with voluntary effort. Tremors assoc. with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine & acetylcholine. Tremors cannot be ↓ by distracting the pt.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? 1. Limit fluid intake to 1,000 mL/ day. 2. Insert an indwelling urinary catheter. 3. Establish a regular voiding schedule. 4. Administer prophylactic antibiotics, as ordered.
3 Maintaining a regular voiding pattern is the MOST appropriate measure to help the pt avoid urinary incontinence. Fluid intake is not r/t incontinence Incontinence is r/t the strength of the detrusor & urethral sphincter muscles. Inserting an indwelling catheter would be a tx of last resort because of the ↑ risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its ↓ risk of infection. Antibiotics DONT influence urinary incontinence.
SEIZURE The nurse sees a client walking in the hallway who begins to have a seizure. The nurse should do which of the following in priority order? 1. Maintain patent airway 2. record the seizure activity observed 3. ease the client to the floor 4. Obtain vital signs
3,1,4,2 Ease the client to the floor Maintain patent airway Obtain vital signs Record the seizure activity observed
What is the priority nursing intervention in the postictal phase of a seizure? 1. Reorient the client to time, person, and place. 2. Determine the client's level of sleepiness. 3. Assess the client's breathing pattern. 4. Position the client comfortably.
3. A PRIORITY for the client in the post-ictal phase (after a seizure) is to assess the client's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen & ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include: - reorientation of the pt to time, person & place. Determining the pt's level of sleepiness is useful, but it is not a priority. Positioning the pt comfortably promotes rest but is of less importance than ascertaining that the airway is patent.
Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? 1. Weight gain. 2. Insomnia. 3. Excessive growth of gum tissue. 4. Deteriorating eyesight.
3. A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does NOT cause weight gain, insomnia, or deteriorating eyesight.
The nurse is teaching a client to recognize an aura. The nurse should instruct the client to note: 1. A postictal state of amnesia. 2. An hallucination that occurs during a seizure. 3. A symptom that occurs just before a seizure. 4. A feeling of relaxation as the seizure begins to subside.
3. An "aura" is a pre-monition of an impending seizure Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur BEFORE a seizure, not during or after (post-ictal). They are NOT similar to hallucinations or amnesia or related to relaxation.
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Temperature.
3. Control of BP is critical during the first 24 hrs after TX because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. VS are monitored, and BP is maintained as identified by the physician & specific to the Pt's ischemic tissue needs & risk of bleeding from TX The other VS are important, but the priority is to monitor BP
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first: 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.
3. Studies show that pts who receive recombinant t-PA TX within 3 hrs after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA TX is critical. A complete health assessment & history is not possible when a pt is receiving emergency care. Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate TX of the current stroke While the nurse should identify which medications the Pt is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering t-PA.
Which of the following is contraindicated for a client with seizure precautions? 1. Encouraging him to perform his own personal hygiene. 2. Allowing him to wear his own clothing. 3. Assessing oral temperature with a glass thermometer. 4. Encouraging him to be out of bed.
3. Temperatures are not assessed orally with a glass thermometer because the thermometer could break & cause injury if a seizure occurred The client can perform personal hygiene. There is no clinical reason to discourage the client from wearing his own clothes. As long as there are no other limitations, the client should be encouraged to be out of bed.
Which nursing intervention has been found to be the most effective means of preventing plantar flexion in a client who has had a stroke with residual paralysis? 1. Place the client's feet against a firm footboard. 2. Reposition the client every 2 hours. 3. Have the client wear ankle-high tennis shoes at intervals throughout the day. 4. Massage the client's feet and ankles regularly.
3. The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot & keep it in the correct anatomic position. Footboards stimulate spasms & are not routinely recommended. Regular repositioning & range-of-motion exercises are important interventions, but the client's foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does NOT prevent plantar flexion & if rigorous, could release emboli.
What is the expected outcome of thrombolytic drug therapy for stroke? 1. Increased vascular permeability. 2. Vasoconstriction. 3. Dissolved emboli. 4. Prevention of hemorrhage.
3. Thrombolytic enzyme agents are used for pt's with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They DO NOT ↑ vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated? 1. Encouraging the client to speak slowly. 2. Encouraging the client to speak distinctly. 3. Asking the client to repeat indistinguishable words. 4. Asking the client to speak louder when tired.
4 Asking a pt to speak louder even when tired may aggravate the problem. Asking the pt to speak slowly & distinctly & to repeat hard-to-understand words helps the pt to communicate effectively.
Which of the following will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure? 1. Jerking in one extremity that spreads gradually to adjacent areas. 2. Vacant staring and abruptly ceasing all activity. 3. Facial grimaces, patting motions, and lip smacking. 4. Loss of consciousness, body stiffening, and violent muscle contractions.
4. A generalized tonic-clonic seizure involves both a tonic phase & a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils & muscular stiffening or contraction, which lasts 20-30 sec. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness & resumption of respiration. A partial seizure starts in one region of the cortex & may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body) An absence seizure usually occurs in children & involves a vacant stare with a brief loss of consciousness that often goes unnoticed A complex partial seizure involves facial grimacing with patting & smacking.
What nursing assessments should be documented at the beginning of the ictal phase of a seizure? 1. Heart rate, respirations, pulse oximeter, and blood pressure. 2. Last dose of anticonvulsant and circumstances at the time. 3. Type of visual, auditory, and olfactory aura the client experienced. 4. Movement of the head and eyes and muscle rigidity.
4. During a seizure, the nurse should note movement of the pt's head, eyes & muscle rigidity, especially when the seizure FIRST begins, to obtain clues about the location of the trigger focus in the brain Other important assessments would include noting the - progression & duration of the seizure - respiratory status - loss of consciousness - pupil size - incontinence of urine & stool It's typically not possible to assess the pt's pulse & BP during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the pt & assessing the onset & progression of the seizure to determine the type of brain activity involved. The type of "aura" should be assessed in the pre-ictal phase of the seizure.
65. Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease? 1. To cure the disease. 2. To stop progression of the disease. 3. To begin preparations for terminal care. 4. To maintain optimal body function.
4. Helping the pt function at his or her best is most appropriate & realistic. Ø There is NO cure for Parkinson's disease. Parkinson's disease progresses in severity & there is no known way to stop its progression. Many pt's live for years with the disease, however, it would not be appropriate to start planning terminal care at this time.
A 21-year-old female client takes clonazepam (Klonopin). What should the nurse ask this client about? Select all that apply. 1. Seizure activity. 2. Pregnancy status. 3. Alcohol use. 4. Cigarette smoking. 5. Intake of caffeine and sugary drinks.
1, 2, 3. The nurse should assess the number & type of seizures the pt has experienced since starting clonazepam monotherapy for seizure control. *The nurse should also determine if the pt might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the pt's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the pt's diet or use of cigarettes for health maintenance & promotion, such information is not specifically related to clonazepam therapy.
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which of the following positions are appropriate? 1. Placing a pillow in the axilla so the arm is away from the body. 2. Inserting a pillow under the slightly flexed arm so the hand is higher than the elbow. 3. Immobilizing the extremity in a sling. 4. Positioning a hand cone in the hand so the fingers are barely flexed. 5. Keeping the arm at the side using a pillow.
1, 2, 4. Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures
STROKE A client is being monitored for transient ischemic attacks. She is oriented, can open her eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score? _____________points.
15 points The Glasgow Coma Scale provides 3 objective neuro assessments: (on a scale of 3-15) 1. spontaneity of eye opening 2. best motor response 3. best verbal response The pt who scores the best on all 3 assessments scores 15 points.
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. The nurse should tell the client: 1. "You will need to accept the necessity for a quiet and inactive lifestyle." 2. "Keep active, use stress reduction strategies, and avoid fatigue." 3. "Follow good health habits to change the course of the disease." 4. "Practice using the mechanical aids that you will need when future disabilities arise."
2 The nurse's most positive approach is to encourage a pt with MS to keep active, use stress reduction strategies & avoid fatigue because it's important to support the immune system while remaining active. A quiet, inactive lifestyle is NOT necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help ↓ complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging.
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS)? 1. Double vision. 2. Sudden bursts of energy. 3. Weakness in the extremities. 4. Muscle tremors.
2 With MS, hyperexcitability & euphoria may occur, but because of muscle weakness, sudden bursts of energy are UNLIKELY Visual disturbances, weakness in the extremities & loss of muscle tone, and tremors are common symptoms of MS.
At what time of day should the nurse encourage a client with Parkinson's disease to schedule the most demanding physical activities to minimize the effects of hypokinesia? 1. Early in the morning, when the client's energy level is high. 2. To coincide with the peak action of drug therapy. 3. Immediately after a rest period. 4. When family members will be available.
2. Demanding physical activity should be performed during the peak action of drug therapy. Pt's should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some pt's may have more energy in the morning or after rest, tremors are managed with drug therapy.
Which food-related behaviors are expected in a client who has had a stroke that has left him with homonymous hemianopia? 1. Increased preference for foods high in salt. 2. Eating food on only half of the plate. 3. Forgetting the names of foods. 4. Inability to swallow liquids.
2. Homonymous hemianopia is blindness in half of the visual field; therefore, the Pt would see only half of his plate. Eating only the food on half of the plate results from an inability to coordinate visual images & spatial relationships. There may be an ↑ preference for foods ↑ in salt after a stroke, but this would NOT be related to homonymous hemianopia. Forgetting the names of foods would be aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX & X, including the lower brain stem.
A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? 1. Sit quietly with the client until the episode is over. 2. Ignore the behavior. 3. Attempt to divert the client's attention. 4. Tell the client that this behavior is unacceptable.
3. A Pt who has brain damage may be emotionally labile & may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the Pt's attention. Ignoring the behavior will not affect the mood swing or the crying & may ↑ the Pt's sense of isolation. Telling the pt to stop is inappropriate.
The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply. 1. Helpfulness. 2. Charity. 3. Firmness. 4. Encouragement. 5. Patience.
4, 5. When offering emotional support to a pt who is discouraged & has a negative self-concept because of physical handicaps, the nurse should approach the pt with encouragement & patience. The pt should be praised when he or she shows progress in efforts to overcome handicaps. An attitude of helpfulness & sympathy allows the pt to assume a role of someone not ordinary, someone who is not like others. Regardless of the handicap, the pt still feels the same on the inside & has the same innate needs for his or her growth & developmental age-group. An attitude of charity tends to make the pt feel like a "charity case" or like someone who is given something free because of his "condition." The pt feels unequal to his peers or unable to fulfill the role relationships that were obtained before the stroke. An approach using firmness is inappropriate because it implies that the pt can do better if he just tries harder & leaves no room for softness in the approach to overcoming a negative self-concept.
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. The nurse should tell the client? 1. "You must shampoo your hair tonight to remove all oil and dirt." 2. "You may drink fluids until midnight, but after that drink nothing until the scan is completed." 3. "You will have some hair shaved to attach the small electrode to your scalp." 4. "You will need to hold your head very still during the examination."
4. The client will be asked to hold the head very still during the examination, which lasts about 30-60 min In some instances, food & fluids may be withheld for 4-6 hrs before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hrs before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.
A client with Parkinson's disease needs a long time to complete her morning hygiene, but she becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse's best initial response in this situation? 1. Tell the client firmly that she needs assistance and help her with her care. 2. Praise the client for her desire to be independent and give her extra time and encouragement. 3. Tell the client that she is being unrealistic about her abilities and must accept the fact that she needs help. 4. Suggest to the client that if she insists on self-care, she should at least modify her routine.
2 Praise the client for her desire to be independent and give her extra time and encouragement. Ongoing self-care is a major focus for pts with Parkinson's disease. The pt should be given additional time as needed & praised for her efforts to remain independent.
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken? 1. At bedtime. 2. All at one time. 3. Two hours before mealtime. 4. At the time scheduled.
4 At the time scheduled While the pt is hospitalized for adjustment of medication, it is essential that the medications be administered EXACTLY at the scheduled time, for accurate evaluation of effectiveness. For example, Sinemet is taken in divided doses over the day, NOT all at one time, for optimum effectiveness.
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use? 1. Wear a patch over one eye. 2. Place personal items on the sighted side. 3. Lie in bed with the unaffected side toward the door. 4. Turn the head from side to side when walking.
4. To expand the visual field, the partially sighted Pt should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight & reach, but most accidents occur from tripping over items that cannot be seen. It may help the Pt to see the door, but walking presents the primary safety hazard.
Which of the following should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. 1. Carefully test the temperature of bath water. 2. Avoid kitchen activities because of the risk of injury. 3. Avoid hot water bottles and heating pads. 4. Inspect the skin daily for injury or pressure points. 5. Wear warm clothing when outside in cold temperatures.
1,3,4,5 A pt with impaired peripheral sensation doesn't feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The pt should be advised to avoid using hot water bottles or heating pads & to protect against cold temperatures. Because the pt cannot rely on minor pain as an indicator of damaged skin or sore spots, the pt should carefully inspect the skin daily to visualize any injuries that he cannot feel. The pt should NOT be instructed to avoid kitchen activities out of fear of injury; independence & self-care are also important. However, the pt should meet with an occupational therapist to learn about assistive devices & techniques that can ↓ injuries, such as burns & cuts that are common in kitchen activities.
The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has? 1. Drowsiness. 2. Inability to move. 3. Paresthesia. 4. Hypotension.
1. The nurse should expect a pt in the post-ictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing & tonic-clonic motor response An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the CNS Hypotension is not typically a problem after a seizure.
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which of the following measures would be most beneficial? 1. Psychotherapy. 2. Regular exercise. 3. Day care for the granddaughter. 4. Weekly visits by another person with MS.
2 An individualized regular exercise program helps the Pt to relieve muscle spasms. The Pt can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data does not indicate that the pt needs psychotherapy, day care for the granddaughter, or visits from other clients.
A client with Parkinson's disease is prescribed levodopa (l-dopa) therapy. Improvement in which of the following indicates effective therapy? 1. Mood. 2. Muscle rigidity. 3. Appetite. 4. Alertness.
2. LevoDOPA is prescribed to ↓ severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a pt with Parkinson's disease.
Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding the client to move up in bed. 3. Lifting the client when moving the client up in bed. 4. Having the client help lift off the bed using a trapeze.
2. Sliding a client on a sheet causes friction & is to be avoided. Friction injures skin & predisposes to pressure ulcer formation. Rolling the pt is an acceptable method to use when changing positions as long as the pt is maintained in anatomically neutral positions & their limbs are properly supported. The pt may be lifted as long as the nurse has assistance & uses proper body mechanics to avoid injury to self or the pt Having the pt help lift themselves off the bed with a trapeze is an acceptable means to move a pt w/o causing friction burns or skin breakdown.
A client states that she is afraid she will not be able to drive again because of her seizures. Which response by the nurse would be best? 1. A person with a history of seizures can drive only during daytime hours. 2. A person with evidence that the seizures are under medical control can drive. 3. A person with evidence that seizures occur no more often than every 12 months can drive. 4. A person with a history of seizures can drive if he carries a medical identification card.
2. Specific motor vehicle regulations & restrictions for people who experience seizures vary locally. Most commonly, evidence that the seizures are under medical control is required before the person is given permission to drive. Time of day is not a consideration when determining driving restrictions related to seizures. The amount of time a person has been seizure-free is a consideration for lifting driving restrictions; however, the time frame is usually 2 Years It is recommended, NOT required, that a person who is subject to seizures carry a card or wear an identification bracelet describing the illness to facilitate quick identification in the event of an emergency.
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will: 1. Develop joint mobility. 2. Develop muscle strength. 3. Develop cognition. 4. Develop mood elevation.
3 MS is a progressive, chronic neurologic disease characterized by patchy de-myelination throughout the CNS. This interferes with the transmission of electrical impulses from one nerve cell to the next. MS affects speech, coordination & vision, but NOT cognition. Care for the pt with MS is directed toward maintaining: - joint mobility - preventing deformities - maintaining muscle strength - rehabilitation - preventing & treating depression - providing pt motivation
MULTIPLE SCLEROSIS The nurse is reviewing the care plan of a client with Multiple Sclerosis. Which of the following nursing diagnoses should receive further validation? 1. Impaired mobility related to spasticity and fatigue. 2. Risk for falls related to muscle weakness and sensory loss. 3. Risk for seizures related to muscle tremors and loss of myelin. 4. Impaired skin integrity related bowel and bladder incontinence.
3 Symptoms that can occur with multiple sclerosis are: - muscle spasticity & weakness - fatigue - visual disturbances - hearing loss - bowel & bladder incontinence Seizures are NOT associated with myelin destruction.
A client is being switched from levodopa (l-dopa) to carbidopa-levodopa (Sinemet). The nurse should monitor for which of the following possible complications during medication changes and dosage adjustment? 1. Euphoria. 2. Jaundice. 3. Vital sign fluctuation. 4. Signs and symptoms of diabetes.
3 Vital sign fluctuation VS should be monitored, especially during periods of adjustment. Changes such as postural hypotension, cardiac irregularities, palpitations & lightheadedness should be reported immediately. The pt may actually experience suicidal or paranoid ideation instead of euphoria. The nurse should monitor the pt for ↑ liver enzymes such as: lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen & alkaline phosphatase, but the pt should NOT be jaundiced. The pt should NOT experience symptoms of diabetes or a low serum glucose, but the nurse should check the hemoglobin & hematocrit levels
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/ 88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? 1. Suction the airway 2.hyperoxygenate 3.suction the mouth 4. Provide sedation
4,2,1,3 Provide sedation Hyperoxygenate Suction the airway Suction the mouth
PARKINSON'S DISEASE A health care provider has ordered carbidopa-levodopa (Sinemet) four times per day for a client with Parkinson's disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply. 1. Explain that the new prescription for Sinemet will treat his depression. 2. Encourage the client to discuss his feelings as the Sinemet is being administered. 3. Contact the health care provider before administering the Sinemet. 4. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. 5. Determine if the client is at risk for suicide.
3, 4, 5. The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in Pts with chronic illness should be taken seriously. The nurse should also determine if the pt is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is NOT a TX for depression. Having the pt discuss his feelings is appropriate when the prescription is finalized.
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate? 1. Eating a diet high in fiber. 2. Setting a regular time for elimination. 3. Using an elevated toilet seat. 4. Limiting fluid intake to 1,000 mL/ day.
4 Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the S/SX of MS. A diet ↑ in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the pt from the wheelchair to the toilet or from a standing to a sitting position
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? 1. "Has an intention tremor of the right hand." 2. "Right-hand tremor worsens with purposeful acts." 3. "Needs assistance with dressing and eating due to severe trembling and clumsiness." 4. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
4 The nurses' notes should be concise, objective, clearly stated & relevant. This pt trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This activity should be described exactly as it occurs so that others reading the note will have no doubt about the nurse's observation of the pt's behavior. Identifying the "intentional" ADL's will help the interdisciplinary team individualize the pt's plan of care. Clarifying what is meant by "worsening" with a purposeful act will facilitate the inter-rater reliability of the team. It is better to state what the pt did than to give vague nursing orders in the nurses' notes.
Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures? 1. Maintain the client on bed rest. 2. Administer butabarbital sodium (phenobarbital) 30 mg P.O., three times per day. 3. Close the door to the room to minimize stimulation. 4. Administer carbamazepine (Tegretol) 200 mg P.O., twice per day.
4. Carbamazepine (Tegretol) is an anticonvulsant that helps prevent further seizures. Bed rest, sedation (phenobarbital), and providing privacy do not minimize the risk of seizures.
