CH 64 Neuro infections++
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine Atropine should be available to control the side effects of edrophonium chloride. Prednisone, azathioprine, and pyridostigmine bromide are not used to counteract these effects.
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 Attaching braces or splints to each foot and leg prevents foot drop (a lower leg contracture) by supporting the feet in proper alignment. Putting slippers on the client's feet can't prevent foot drop because slippers are too soft to support the ankle joints. Crossing the ankles every 2 hours is contraindicated because it can cause excess pressure and damage veins, promoting thrombus formation. Placing hand rolls on the balls of each foot doesn't prevent contractures because hand rolls are too soft to support and hold the feet in proper alignment.
The nurse is working with a rehabilitation client who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation?
Helping the client perform frequent exercise Regaining the ability to walk is a prime morale builder. However, to be prepared for ambulation—whether with brace, walker, cane, or crutches—the client must strengthen the muscles required. Therefore, exercise is the foundation of preparation.
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 Protein is the nutrient important for overall tissue repair. Vitamin C promotes collagen synthesis and supports the integrity of the capillary wall. Water is important to maintain homeostasis. Zinc sulfate acts as a cofactor for collagen formation.
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 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.
A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.
x-----indwelling catheter output x-----family history of pressure ulcers v-----presence of pressure ulcers on the client v-----overall risk of developing pressure ulcers v-----potential areas of pressure ulcer development When assessing skin integrity, the overall risk potential of developing pressure ulcers takes priority. Overall risk assessment encompasses review of existing pressure ulcers as well as potential areas for development of pressure ulcers. Foley catheter output and family history of pressure ulcers are not important when assessing skin integrity.
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." The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.
The nurse is performing range-of-motion exercises. Which of the following best depicts dorsiflexion of the foot?
(specific to images) With dorsiflexion (Option B), the nurse moves the foot up and down toward the leg. Flexion of the hip and knee (Option A) involves bending the hip by moving the leg forward as afar as possible and then returning it to the neutral position. Inversion and eversion (Option C) involves moving the foot so that the sole is facing outward (eversion) and then so that the sole is facing inward (inversion). Flexion of toes (Option D) involves bending the toes toward the ball of the foot.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.
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 client demonstrates quadriceps-setting exercises by attempting to push the popliteal area against the mattress and at the same time raising the heel. With gluteal setting exercises, the client contracts the buttocks together for a count of five and then relaxes them for a count of five. With push-up exercises, the client raises the body by pushing the hands against the chair seat or mattress while he is in a sitting position. For pull-up exercises, the client lifts the body off the mattress while holding onto a trapeze while in bed or raises the arms above the head then lowers them while holding weights.
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)?
Tensilon test Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.
A nurse is performing range-of-motion exercises and moves the patient's hand sideways so that the little finger moves toward the forearm. The nurse is performing which of the following?
Ulnar deviation Moving the hand sideways so that the side of the hand with the little finger moves toward the forearm reflects ulnar deviation. Supination occurs when the elbow is at the waist, the arm is bent at a 90-degree angle, and the hand is turned so that the palm is facing up. Thumb opposition occurs when the thumb moves out and around to touch the little finger. Wrist flexion occurs when the wrist is bent so that the palm is toward the forearm.
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate?
Initiate seizure precautions. A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The client may experience expressive aphasia related to the abscess, but that does not indicate the need to ensure the client takes in nothing by mouth.
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 Serum albumin and prealbumin levels are sensitive indicators of protein deficiency. Serum albumin levels of less than 3 g per dL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers. Serum glucose is used to assess for diabetes. Prothrombin time is used to assess clotting time and monitor therapeutic levels of anticoagulation medications. Sedimentation rate is used to detect inflammation in the body.
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. Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
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. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.
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. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.
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. For clients with disabilities, the nurse would emphasize the use of coping strategies and teach the patient how to cope with the disability through priority setting. A loss of sexual functioning does not necessarily correspond to a loss of sexual feeling. Rather, the physical and emotional aspects of sexuality, despite the physical loss of function, continue to be important for people with disabilities. The fatigue associated with disabilities results from numerous factors, such as the physical and emotional demands, as well as the ineffective coping, unresolved grief, disordered sleep patterns, and depression. Although the most obvious care tasks after discharge involve physical care, other elements of the caregiving role include psychosocial support and a commitment to this supportive role.
The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's:
range of motion. Each joint of the body has a normal range of motion. To assess a client for contractures, the nurse should assess whether the client can complete the full range of motion. Assessing DTRs, muscle size, or joint pain does not reveal the presence or absence of contractures.
The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?
Appropriate assistive devices Clients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A health care aide is not needed by most clients.
