Chapter 37: Caring for Clients with Central and Peripheral Nervous System Disorders Med- Surg Prep U
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate
Which client should the nurse assess for degenerative neurologic symptoms?
The client with Huntington disease.
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant?
Uneven, labored respirations
The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The client's activities immediately prior to the seizure.
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort
The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?
Providing ventilatory assistance
A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?
3
The nurse has created a plan of care for a client who is at risk for increased ICP. The client's care plan should specify monitoring for what early sign of increased ICP?
Disorientation and restlessness
The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client?
5 to 15 mm Hg
The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa for 7 years. For what common side effect should the nurse assess this client?
Dyskinesia
During the examination of an unconscious client, the nurse observes that the client's pupils are fixed and dilated. What is the most plausible clinical significance of the nurse's finding?
It indicates an injury at the midbrain level.
A client newly diagnosed with Huntington diease asks for information concerning management of symptoms. Which action would the nurse first take to address this request?
Perform a focused assessment on the client's needs and capabilities.
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?
Place the client in a side-lying position.
The nurse is caring for a patient with Huntington's disease in the long-term care facility. What does the nurse recognize as the most prominent symptom of the disease that the patient exhibits?
Rapid, jerky, involuntary movements
A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing?
Secondary headache
After a seizure, the nurse should place the patient in which of the following positions to prevent complications?
decreased level of consciousness (LOC)
A patient with Huntington's disease is prescribed medication to reduce the chorea. What medication will the nurse administer that is the only drug approved for the treatment of this symptom?
Tetrabenazine (Xenazine)
A client with suspected Parkinson disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?
When the client is resting
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply.
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following?
Loss of brain stem reflexes
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment?
Lumbar puncture
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Semisolid food with thick liquids
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?
Shivering
What is one of the earliest signs of increased ICP?
Side-lying, to facilitate drainage of oral secretions
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?
Increased ICP
A client is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this client's care, the nurse would expect to administer what priority medication?
Mannitol
The critical care nurse is caring for 25-year-old client admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client?
Monitoring neurologic status closely
A client presents to the clinic reporting a headache. The nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. The nurse suspects the client may have meningitis. What is another well-recognized sign of this infection?
Positive Kernig sign
The nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge?
The patient should perform frequent physical activity but avoid becoming fatigued.
A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure?
unequal response
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?
Generalized
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 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 nurse is caring for a client with Parkinson disease (PD). Which finding in the client's medical record will cause the nurse to question giving a prescribed dose of benztropine mesylate?
Narrow-angle glaucoma
The nurse is caring for a client diagnosed with Parkinson disease. The client is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the client to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
Use of a raised toilet seat
A client with a metastatic brain tumor of the frontal lobe experiences a generalized seizure for the first time. The nurse should prepare for what action?
Administration of anticonvulsants
The nurse is caring for a client with a brain tumor and is aware that the normal compensation measures to keep ICP (intracranial pressure) within normal limits may no longer be effective. What are the normal compensation measures for the brain? Select all that apply.
Displacing or shifting cerebral spinal fluid (CSF) Decreasing cerebral blood volume Increasing the absorption of CSF
A client, brought to the clinic by the client's spouse and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
Emotional and personality changes
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the emergency department (ED). The nurse should first gauge the client's LOC on the results of what diagnostic tool?
Glasgow Coma scale
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the client's restrictive clothing.
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?
"I was brushing my teeth."
The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse?
"If one parent has the disorder, there is a 50% chance that you will inherit the disease."
A client asks the nurse to explain the development of Parkinson disease (PD). Which response will the nurse provide the client?
"It is caused by low levels of dopamine that are not available to counteract the effects of acetylcholine."
A client with Parkinson disease is experiencing episodes of constipation that are becoming increasingly frequent and severe. The client reports that he has been achieving relief for the past few weeks by using over-the-counter laxatives. How should the nurse respond?
"Let's explore other options, because laxatives can have side effects and create dependency."
Which value indicates a normal intracranial pressure (ICP)?
5 mm Hg
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?
70 mm Hg
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure
A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?
As soon as the client senses the onset of symptoms
Which is the earliest sign of increasing intracranial pressure?
Change in level of consciousness
A patient diagnosed with multiple sclerosis (MS) has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What would be the expected outcome of this medication?
Decreased muscle spasms in the lower extremities
A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care?
Difficulty in coordination
The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?
Fluid restriction
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
Generalized seizure
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?
Glasgow Coma Scale
A client is diagnosed with a brain angioma. When teaching the client about the risks associated with this type of brain tumor, the nurse would educate about signs and symptoms associated with which condition?
Hemorrhagic stroke
A 50-year-old client is exhibiting progressive signs of Huntington's disease. The client verbalizes a wish to die and has become withdrawn. Poor appetite is noted, sleep pattern is disturbed, and the choreiform movements are worsening. Which nursing diagnosis best reflects the needs of this client?
Hopelessness
The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication?
Increased muscle strength
The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?
Inform the care team and assess for further signs of possible increased ICP.
The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan?
Instruct the client on daily muscle stretching
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?
Lethargy and stupor
A client with increased intracranial pressure (ICP) has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication?
Meningitis
The nurse is caring for a client who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of "deficient fluid volume related to fluid restriction and osmotic diuretic use." What is the nurse's most appropriate intervention for this diagnosis?
Monitor serum electrolytes.
A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case?
Narcotic analgesics increase CSF pressure.
A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate?
Notify the physician of a possible cerebrospinal fluid leak.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women?
Osteoporosis
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
Parkinson disease.
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?
Phenytoin
A client with a new diagnosis of amyotrophic lateral sclerosis (ALS) is overwhelmed by the diagnosis and the known complications of the disease. How can the client best make known their wishes for care as the disease progresses?
Prepare an advance directive.
A client experiences a seizure while hospitalized for appendicitis. During the postictal phase, the client is yelling and swings a closed fist at the nurse. Which is the appropriate action by the nurse?
Reorient the client while gently holding their arms.
A community health nurse is performing a home visit to a patient with amyotrophic lateral sclerosis (ALS). The nurse should prioritize assessments related to which of the following?
Respiratory function
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method?
Semisolid food with thick liquids
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.
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 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?
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:
Tremors and muscle rigidity
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
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?
Within 24 hours after exposure
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
The primary arthropod vector in North America that transmits encephalitis is the
mosquito.
While caring for a client with a seizure disorder, the nurse observes a sudden, brief jerking of the client's left arm. Most likely, the client has which type of seizure disorder?
myoclonic seizure
The nurse teaches the client that corticosteroids will be used to treat his brain tumor to
reduce cerebral edema.
A client with a neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing action is critical for this client?
restricting fluid intake and hydration
The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the
supine position with the head slightly elevated.
Myasthenia gravis occurs when antibodies attack which receptor sites?
Acetylcholine
A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?
Close monitoring of fluid balance
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?
Decerebrate posturing and loss of corneal reflex
A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?
Declining level of consciousness (LOC)
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?
Dyskinesia
The nurse is performing an assessment for a patient in the clinic with Parkinson's disease. The nurse determines that the patient's voice has changed since the last visit and is now more difficult to understand. How should the nurse document this finding?
Dysphonia
The nurse is writing a care plan for a client with brain metastases. The nurse decides that an appropriate nursing diagnosis is "anxiety related to lack of control over the health circumstances." In establishing this plan of care for the client, the nurse should include which intervention?
Encouragement to verbalize concerns related to the disease and its treatment
Which nursing intervention is most helpful when addressing the priority nursing diagnosis of Impaired Physical Mobility related to damage of brain tissue as evidenced by visual deficits and absence of portions of the visual field?
Ensure a clutter-free walkway.
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode?
Compliance with the prescribed medication regimen
A client with head trauma is taken to surgery to insert an ICP monitor as signs and symptoms indicating increased ICP have continued to worsen. What increase in ICP (from a previous measurement) is cause for concern?
2 mm Hg
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?
Administering a stool softener as ordered
A client is undergoing treatment for a glioblastoma. Because of a potential risk of imbalanced nutrition, attention should be given to dietary requirements. Which nursing interventions may be taken to ensure nutritional requirements are met? Select all that apply.
Adopt techniques to modify the texture and consistency of foods. Offer liquid nutritional supplements in between meals.
Which is a late sign of increased intracranial pressure (ICP)?
Altered respiratory patterns
The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication?
Autonomic dysfunction
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state?
Confusion
The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease?
Facial paralysis
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?
Maintains a patent airway
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?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?
chewing
