Chapter 37: Caring for Clients with Central and Peripheral Nervous System Disorders - ML4

A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process?

Acyclovir

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 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

A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?

Blurred vision, intention tremor, and urinary hesitancy

The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is

Change in level of consciousness

Which is the earliest sign of increasing intracranial pressure?

Change in level of consciousness

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 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

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

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.

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

The nurse is caring for a client who has developed SIADH. What intervention is most appropriate?

Fluid restriction

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

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

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?

Maintenance of a patent airway

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

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.

A client newly diagnosed with Huntington disease 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 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

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

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

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

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

mosquito.

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 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 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."

An older adult has encouraged the spouse husband to visit their primary provider, stating that concern that spouse may have Parkinson disease. Which description of the spouse's health and function is most suggestive of Parkinson disease?

"Lately he seems to move far more slowly than he ever has in the past."

A client presents at the clinic with pain and weakness in the hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what condition?

Peripheral nerve disorder

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

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

Which of the following medication classifications is utilized preoperatively to decrease risk of postop seizures?

Anticonvulsants

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

Assessing respiratory effort

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 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

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

The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action?

Participate in interventions to increase cerebral perfusion pressure (CPP).

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side.

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 nurse knows that a patient exhibiting seizure-like movements localized to one side of the body most likely has what type of tumor?

A motor cortex tumor

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.

A client is diagnosed with a brain abscess. Which medication will the nurse anticipate providing to the client? Select all that apply.

Metronidazole Dexamethasone Lacosamide

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.

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 patient with Parkinson's disease is experiencing an on-off syndrome. What does the nurse recognize that the patient's clinical symptoms will be?

The patient will have periods of near immobility, followed by a sudden return of effectiveness of the medication.

A nurse is caring for a client with a diagnosis of trigeminal neuralgia. Which activity is altered as a result of this diagnosis?

chewing

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

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

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of knees and hips

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.

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 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."

A client weighing 132 lb is brought to the emergency department in status epilepticus. The physician asks the nurse to prepare diazepam 0.25 mg/kg. How many milligrams will be given to this client?

15

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 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 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

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

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 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 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

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

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

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

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.

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 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 client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because:

shivering in hypothermia can increase ICP.