Ch 69 - Autoimmune disorders, neurologic infections, neuropathies

A patient has been diagnosed with a frontal lobe brain abscess. Which of the following nursing interventions is appropriate? a) Initiate seizure precautions. b) Ensure that patient takes nothing by mouth (NPO). c) Assess for facial weakness. d) Assess visual acuity.

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 patient may experiences expressive aphasia related to the abscess, but that does not indicate the need to ensure the patient is NPO.

Within the acute care facility where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident and closed head injury. While caring for these clients, what was an important nursing goal that motivated you to offer the best care possible? a) Prevent complications, which may interfere with recovering function. b) Prevent infection. c) Prevent falls. d) Prevent choking.

Prevent complications, which may interfere with recovering function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function. During this phase, the goal of care is to prevent complications, which may interfere with recovery.

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? a) Lymphoma b) Leukemia c) Virus d) Bacteria

Bacteria Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.

The nurse is expecting to admit a client with a diagnosis of meningitis. While preparing the client's room, which of the following would the nurse most likely have available? a) Equipment to maintain infection control precautions b) Extra lighting c) Nasogastric tubing d) IV tensilon

Equipment to maintain infection control precautions An important component of nursing care for the client with meningits is instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Oral and nasal discharge is considered infectious. This client may well experience photophobia, so the lighting should be kept dim. IV Tensilon is used to diagnose myasthenia gravis.

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? a) "Have you experienced any ptosis in the last few weeks?" b) "Have you had difficulty with urination in the last 6 weeks?" c) "Have you experienced any viral infections in the last month?" d) "Have you developed any new allergies in the last year?"

"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. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? a) "I was taking a bath." b) "I was brushing my teeth." c) "I was sitting at home watching television." d) "I was putting my shoes on."

"I was brushing my teeth." Trigeminal neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. Paroxysms can occur with any stimulation of the terminals of the affected nerve branches, such as washing the face, shaving, brushing the teeth, eating, and drinking.

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? a) Place the patient in the supine position. b) Administer atropine to control the side effects of edrophonium. c) Call the rapid response team because the patient is preparing to arrest. d) Administer diphenhydramine (Benadryl) for the allergic reaction.

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 who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate? a) Encourage the client to close his eyes. b) Alternatively patch one eye every 2 hours. c) Instill artificial tears. d) Turn out the lights in the room.

Alternatively patch one eye every 2 hours. Patching one eye at a time relieves diplopia (double vision). Closing the eyes and making the room dark aren't the most appropriate options because they deprive the client of sensory input. Artificial tears relieve eye dryness but don't treat diplopia.

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? a) Assess the respiratory rate and oxygen saturation. b) Listen to the bowel sounds. c) Assess the blood pressure and heart rate. d) Assess the peripheral pulses.

Assess the blood pressure and heart rate. The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed.

Which of the following is the priority nursing intervention for a patient in myasthenic crisis? a) Ensuring adequate nutritional support b) Administering intravenous immunoglobin (IVIG) per orders c) Assessing respiratory effort d) Preparing for plasmapheresis

Assessing respiratory effort A patient 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. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

Which drug should be available to counteract the effect of Tensilon? a) Imuran b) Prednisone c) Mestinon d) Atropine

Atropine Atropine should be available to control the side effects of Tensilon. Prednisone, Imuran, and Mestinon are not used to counteract these effects.

A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? a) Avoid physical activity. b) Take moderate amounts of alcohol. c) Avoid hot temperatures. d) Avoid analgesic medication.

Avoid hot temperatures. Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems? a) Wernicke's abscess b) Frontal lobe abscess c) Temporal lobe abscess d) Cerebellar abscess

Cerebellar abscess Indicators of a cerebellar abscess include occipital headache, ataxia, and nystagmus.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? a) Numbness b) Diplopia and ptosis c) Loss of proprioception d) Patchy blindness

Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

Bell's palsy is a disorder of which cranial nerve? a) Trigeminal (V) b) Vagus (X) c) Vestibulocochlear (VIII) d) Facial (VII)

Facial (VII) Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

Which of the following is the most common clinical manifestation of multiple sclerosis? a) Pain b) Spasticity c) Ataxia d) Fatigue

Fatigue Fatigue affects 87% of people with MS and 40% of that group indicate that fatigue is the most disabling symptom. Pain, spasticity, and ataxia are clinical manifestations of MS.

The diagnosis of multiple sclerosis is based upon which of the following tests? a) Evoked potential studies b) CSF electrophoresis c) Neuropsychological testing d) MRI

MRI The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

Which of the following is considered a central nervous system (CNS) disorder? a) Bell's palsy b) Multiple sclerosis c) Guillain-Barré d) Myasthenia gravis

Multiple sclerosis Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

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? a) Muscle weakness and hyporeflexia of the lower extremities b) Ptosis and muscle weakness of upper extremities c) Hyporeflexia and skin rash d) Fever and cough

Muscle weakness and hyporeflexia of the lower extremities Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities. Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications? a) Placement of a feeding tube b) Placement of a urinary catheter c) Placement of a tracheostomy tube d) Placement of a colostomy tube

Placement of a feeding tube Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube may need to be placed if the deficit is prolonged and if the client is unable to eat. Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube would be placed to address this deficit.

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? a) Negative Brudzinski's sign b) Positive Romberg sign c) Hyper-alertness d) Positive Kernig's sign

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 completly extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.

A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? a) Benign b) Primary progressive c) Relapsing-remitting (RR) d) Disabling

Relapsing-remitting (RR) Approximately 85% of patients with MS have a relapsing-remitting (RR) course. With each relapse, recovery is usually complete; however, residual deficits may occur and accumulate over time, contributing to functional decline.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? a) Acts as chemical messenger b) Carries message to the next nerve cell c) Speeds nerve impulse transmission d) Represents building block of nervous system

Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following? a) Blindness b) Bulbar weakness c) Inability to swallow d) Tachycardia

Tachycardia Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.

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? a) The client arranges a community service to deliver meals. b) The client uses a mechanical lift to climb steps. c) The client ambulates with the assistance of one. d) The client grasps the affected arm at the wrist and raises it.

The client grasps the affected arm at the wrist and raises it. The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? a) Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. b) After administration of the medication, there will be no change in the status of the ptosis or facial weakness. c) Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. d) The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon.

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? a) Within 72 hours after exposure b) Within 24 hours after exposure c) Within 48 hours after exposure d) Therapy is not necessary prophylactically and should only be used if the person develops symptoms.

Within 24 hours after exposure People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at a) controlling seizures and increased intracranial pressure. b) preventing renal insufficiency. c) preventing muscular atrophy. d) maintaining hemodynamic stability and adequate cardiac output.

controlling seizures and increased intracranial pressure. There is no specific medication for arbovirus encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

The primary North American vector transmitting arthropod-borne virus encephalitis is the a) horse. b) flea. c) tick. d) mosquito

mosquito Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? (Select all that apply.) a) Have the patient take a hot tub bath to allow muscle relaxation. b) Assist with a rigorous exercise program to prevent contractures. c) Demonstrate daily muscle stretching exercises. d) Allow the patient adequate time to perform exercises e) Apply warm compresses to the affected areas.

• Allow the patient adequate time to perform exercises • Demonstrate daily muscle stretching exercises. • Apply warm compresses to the affected areas. Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? (Select all that apply.) a) Allow the patient adequate time to perform exercises b) Apply warm compresses to the affected areas. c) Demonstrate daily muscle stretching exercises. d) Have the patient take a hot tub bath to allow muscle relaxation. e) Assist with a rigorous exercise program to prevent contractures.

• Demonstrate daily muscle stretching exercises. • Apply warm compresses to the affected areas. • Allow the patient adequate time to perform exercises Warm packs may be beneficial for relieving spasms, but hot baths should be avoided because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Daily exercises for muscle stretching are prescribed to minimize joint contractures. The patient should not be hurried in any of these activities, because this often increases spasticity.

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. a) Increased protein b) Decreased protein c) Increased white blood cells d) Decreased glucose e) Increased glucose

• Increased white blood cells • Increased protein • Decreased glucose CSF studies demonstrate decreased glucose, increased protein levels, and increased white blood cells.

Which of the following nursing interventions is appropriate for a patient with double vision in the right eye due to MS? a) Exercise the right eye twice a day (BID). b) Apply an eye patch to the right eye. c) Administer eye drops as needed. d) Place needed items on the right side.

Apply an eye patch to the right eye. An eye patch to the affected eye would help the patient with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the patient. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a patient with double vision. Needed items should be placed on the unaffected (left) side.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? a) Acts as chemical messenger b) Represents building block of nervous system c) Speeds nerve impulse transmission d) Carries message to the next nerve cell

Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a) Brudzinski's sign. b) a positive sweat chloride test. c) a positive edrophonium (Tensilon) test. d) Kernig's sign.

a positive edrophonium (Tensilon) test. A positive edrophonium test confirms the diagnosis of myasthenia gravis. After edrophonium administration, most clients with myasthenia gravis show markedly improved muscle tone. Kernig's sign and Brudzinski's sign indicate meningitis. The sweat chloride test is used to confirm cystic fibrosis.

The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse? a) "Don't worry; your child will be fine." b) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." c) "Once Guillain-Barré syndrome progresses to the diaphragm there is a significant decrease in surviving." d) "It's too early to give a prognosis."

"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 patient may make a full recovery or suffer from some residual deficits. Telling the parents not to worry is dismissing their feelings and not addressing their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but 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.

Which of the following is the priority nursing intervention for a patient in myasthenic crisis? a) Ensuring adequate nutritional support b) Assessing respiratory effort c) Preparing for plasmapheresis d) Administering intravenous immunoglobin (IVIG) per orders

Assessing respiratory effort A patient 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. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease? a) Red blood cells present in the CSF b) Glucose in the CSF c) White blood cells in the CSF d) Elevated protein levels in the CSF

Elevated protein levels in the CSF Serum laboratory tests are not useful in the diagnosis. However, elevated protein levels are detected in CSF evaluation, without an increase in other cells.

A patient has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the patient was complaining of neck stiffness earlier in the day. What action should the nurse do first? a) Administer prescribed antibiotics. b) Ensure the family receives prophylaxis antibiotic treatment. c) Initiate isolation precautions. d) Apply a cooling blanket.

Initiate isolation precautions. The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and patients against the spread of the bacteria. Patients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics following the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done following 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.

The diagnosis of multiple sclerosis is based on which of the following tests? a) Cerebrospinal fluid (CSF) electrophoresis b) Magnetic resonance imaging (MRI) c) Evoked potential studies d) Neuropsychological testing

Magnetic resonance imaging (MRI) The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? a) Huntington disease b) Parkinson's disease c) Creutzfeldt-Jakob disease d) Multiple sclerosis (MS)

Multiple sclerosis (MS) The cause of MS is not known and the disease affects twice as many women as men. Parkinson's 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 CNS characterized by spongiform degeneration of the gray matter of the brain.

The initial symptoms of variant Creutzfeldt-Jakob disease (vCJD) include which of the following? a) Akathisia and dysphagia b) Muscle rigidity, memory impairment, and cognitive impairment c) Sensory disturbance, limb pain, and behavioral changes d) Diplopia and bradykinesia

Sensory disturbance, limb pain, and behavioral changes Sensory disturbance, limb pain, and behavioral changes are the initial symptoms of vCJD. Muscle rigidity, memory impairment, and cognitive impairment occur late in the course of vCJD. The other symptoms listed may happen in the later stages of vCJD.

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? a) Suggest applying cool compresses on the face several times a day to tighten the muscles. b) Inform the patient that the muscle function will return as soon as the virus dissipates. c) Tell the patient to smile every 4 hours. d) Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

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 with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? a) There should not be a problem, since the medication was only delayed by about 2 hours. b) The patient will require a double dose prior to lunch. c) The muscles will become fatigued and the patient will not be able to chew food or swallow pills. d) The patient will go into cardiac arrest.

The muscles will become fatigued and the patient will not be able to chew food or swallow pills. Maintenance of stable blood levels of anticholinesterase medications, such as pyridostigmine (Mestinon), is imperative to stabilize muscle strength. Therefore, the anticholinesterase medications must be administered on time. Any delay in administration of medications may exacerbate muscle weakness and make it impossible for the patient to take medications orally.

The most common cause of cholinergic crisis includes which of the following? a) Overmedication b) Compliance with medication c) Undermedication d) Infection

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. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.

Stephen Oswald, a 68-year-old retired salesman, was brought by squad into the acute care facility where you practice nursing. His wife accompanies him and relates how Stephen reported a severe headache and then was unable to talk or move his right arm and leg. After diagnostics are completed and Mr. Oswald is admitted to the hospital, when would you expect basic rehabilitation to begin? a) Two to 3 days b) Immediately c) Upon transfer to a rehabilitation unit d) After 1 week

Immediately Beginning basic rehabilitation during the acute phase is an important nursing function. Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function. Basic rehabilitation begins during the acute phase and is an important nursing function.

The patient with herpes simplex virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) signs and symptoms of cardiac insufficiency. b) renal complications related to acyclovir therapy. c) signs of improvement in the patient's condition. d) signs of relapse.

renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. To prevent relapse treatment with acyclovir should continue for up to 3 weeks. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Myasthenia gravis occurs when antibodies attack which receptor sites? a) Dopamine b) Gamma-aminobutyric (GABA) c) Serotonin d) Acetylcholine

Acetylcholine In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? a) The client will take the seizure medication at the same time daily. b) The client will post emergency numbers on the refrigerator for ease of obtaining. c) The client will remain free of injury if a seizure does occur. d) The client will verbalize an understanding of feelings that preempt seizure activity.

The client will remain free of injury if a seizure does occur. All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.

Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)? a) Initiating isolation procedures b) Preparing for organ donation c) Administering amphotericin B d) Providing supportive care

Providing supportive care The nvCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of nvCJD, nursing care is primarily supportive. Prevention of disease transmission is an important part of providing nursing care. Although patient isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for nvCJD.

The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education? a) "The exercises should be completed quickly to reduce fatigue." b) "I should participate in non-weight-bearing exercises." c) "I will take hot tub baths to decrease spasms." d) "I will stretch daily as directed by the physical therapist."

"I will stretch daily as directed by the physical therapist." Hot baths are discouraged due to the risk of injury. Patients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Patients should not hurry through the exercise activity as it may increase muscle spasticity.

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? a) 1 hour after the antibiotic has infused and daily for 7 days b) 2 hours prior to the administration of antibiotics for 7 days c) It can be administered every 6 hours for 10 days. d) 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days

15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding (Bader & Littlejohns, 2010).

Which of the following is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain? a) Huntington disease b) Creutzfeldt-Jakob disease c) Parkinson's disease d) Multiple sclerosis

Creutzfeldt-Jakob disease Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the CNS characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson's disease is associated with decreased levels of dopamine due to 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.

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? a) Hyporeflexia and weakness of the lower extremities b) Ptosis and diplopia c) Facial distortion and pain d) Fatigue and depression

Facial distortion and pain Bell's palsy is manifested by facial distortion, increased tearing, and painful sensations in the face, behind the ear, and in the eye. Ptosis and diplopia are associated with myasthenia gravis. Hyporeflexia and weakness of the lower extremities are associated with Guillain-Barre syndrome. Fatigue and depression are associated with multiple sclerosis.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? a) Lung auscultation and measurement of vital capacity and tidal volume b) Evaluation of pain and discomfort c) Evaluation of nutritional status and metabolic state d) Evaluation for signs and symptoms of increased intracranial pressure (ICP)

Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop. The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? a) Neurovascular system b) Endocrine system c) Cardiovascular system d) Respiratory system

Neurovascular system The client is exhibiting signs of an evolving cerebrovascular accident, possibly hemorrhagic in nature, with neurologic complications. Nursing assessment will focus on the neurovascular system assessing level of consciousness, hand grasps, communication deficits, etc. Continual cardiovascular assessment is important but not the main focus of assessment. Respiratory compromise is not noted as a concern. The symptoms exhibited are not from an endocrine dysfunction.

Which of the following is the first-line therapy for myasthenia gravis (MG)? a) Pyridostigmine bromide (Mestinon) b) Lioresal (Baclofen) c) Azathioprine (Imuran) d) Deltasone (Prednisone)

Pyridostigmine bromide (Mestinon) Mestinon, an anticholinesterase medication, is the first-line therapy in MG. It provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. If Mestinon does not improve muscle strength and control fatigue, the next agents used are immunosuppressant agents. Imuran is an immunosuppressive agent that inhibits T lymphocytes and reduces acetylcholine receptor antibody levels. Baclofen is used in the treatment of spasticity in MG.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? a) Represents building block of nervous system b) Speeds nerve impulse transmission c) Carries message to the next nerve cell d) Acts as chemical messenger

Speeds nerve impulse transmission Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

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? a) Trigeminal neuralgia b) Migraine headache c) Bell's palsy d) Angina pectoris

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 patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for a) hypoxia. b) renal insufficiency. c) mood changes and fluid and electrolyte alterations. d) leukopenia and cardiac toxicity.

leukopenia and cardiac toxicity. Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lymphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity. Patients receiving corticosteroids are monitored for side effects related to corticosteroids such as mood changes and fluid and electrolyte alterations. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.