CH 64: Neurologic Infections, Autoimmune disorders, and neuropathies

The nurse is caring for a client with tetraplegia following a motor vehicle accident. A family member of the client states, "I know there is grief associated with the loss of independence, but how do I help my loved one to move past that?" The nurse is most helpful to say which of the following?

"Grief is a normal process. Let's discuss offering support throughout the process."

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?

"Have you experienced any viral infections in the last month?" An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin.

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 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 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

What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?

A diet high in carbohydrates

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client?

A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"

While assessing a patient's sacral area, the nurse observes a stage I pressure ulcer. Which of the following images best depicts what the nurse has observed?

A stage I pressure ulcer is characterized by erythema that does not blanch with pressure and progresses to dusky blue-gray, with elevated temperature of the surrounding skin, swollen and congested tissue, and complaints of discomfort. A stage II ulcer is a partial-thickness wound characterized by breaks in the skin, edema, drainage, and possible infection. A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue, has drainage and necrosis, and most likely is infected. A stage IV pressure ulcer is a full-thickness wound that extends to underlying muscle and bone, with necrosis, drainage, and deep pockets of infection.

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 A wound (regardless of its size) that contains tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place.

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

Applying knee splints

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

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

Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early.

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.

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 Creutzfeldt-Jakob disease causes severe dementia and myoclonus.

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

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)

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 rehabilitation nurse is assisting a patient to cope with a disability. Which of the following would the nurse suggest?

Emphasize areas of strengths.

The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action?

Ensure atropine is readily available.

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.

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve. Trigeminal neuralgia is a paralysis of the trigeminal nerve (cranial nerve V). The optic nerve (cranial nerve II) functions in vision. The vestibulocochlear nerve (cranial nerve VIII) functions in hearing.

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

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

Functional Independence Measure

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 and bowel sounds

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

Headache and nuchal rigidity

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus

The nurse assesses initial skin redness in a patient who is at risk for skin breakdown. How should the nurse document this finding?

Hyperemia

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.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

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 Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the client. Passive exercises are carried out by the therapist or the nurse without assistance from the client. Resistive exercises are carried out by the client working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.

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 nutritional deficiency may delay wound healing?

Lack of vitamin C Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for wound healing. Adequate protein intake is necessary for improving skin integrity. Vitamin D and calcium are necessary for bone healing.

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI)

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following?

Maintains effective respirations and airway clearance

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

Moisture

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?

Multiple sclerosis

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

Multiple sclerosis

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 cause of MS is not known, and the disease affects twice as many women as men. Parkinson disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain.

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 Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities.

A nurse is performing passive range of motion to a client's upper extremities. The nurse touches the client's thumb to each fingertip on the same hand. The nurse is performing which of the following?

Opposition

The most common cause of cholinergic crisis includes which of the following?

Overmedication A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure.

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

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction.

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 A positive Brudzinski's sign is a common finding in the client with meningitis. When the client's neck is flexed, flexion of the knees and hips is produced. A positive Kernig's sign is usual with meningitis. The client will develop lethargy as the illness progresses.

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following?

Positive Kernig's sign A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis.

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.

The nurse is evaluating the serum albumin of a client newly admitted on the rehabilitation unit. The nurse determines that the client's serum albumin concentration is low, indicating that the client has which deficiency?

Protein

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

Providing palliative care Providing supportive care

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

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

Reduced muscle spasticity

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?

Renal

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?

Repositioning the patient about once a shift Turning should occur every 1 to 2 hours — not once a shift — for patients who are in bed for prolonged periods.

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

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?

Ring or donut

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.

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 The bacteria Streptococcus pneumoniae and Neisseria meningitides are responsible for 80% of cases of meningitis in adults.

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

Stress incontinence

A patient who has a disability is attempting to gain employment via vocational rehabilitation. What should the nurse closely monitor in the patient with a disability attempting to seek employment?

Substance abuse

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. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.

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

A client has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the client is admitted to a rehabilitation facility?

The ability to perform ADLs may be the key to re-entering the community.

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 caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?

The client will experience grief in an individualized manner.

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 nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then:

advance both crutches.

A neurologic deficit is best defined as a deficit of the:

central and peripheral nervous systems with decreased, impaired, or absent functioning.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at

controlling seizures and increased intracranial pressure.

The primary arthropod vector in North America that transmits encephalitis is the

mosquito.

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development

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.

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure

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

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

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.

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.

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye. An eye patch to the affected eye would help the client with double vision see more clearly, thus promoting safety.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction.

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. Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

Administer prescribed antibiotics.

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

Students are reviewing information about activities of daily living. They demonstrate understanding of this topic when they identify which of the following as an activity of daily living?

Bathing

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.

Bathing Toileting Eating

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 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 Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility?

Turning the client every 2 hours and providing a low-air-loss mattress

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?

Uneven, labored respirations