Chapter 40
Clients who have suffered neurologic deficits from various causes, including cerebrovascular accident, closed head injury, etc., have all experienced which phase of neurologic deficit?
Acute
During a Tensilon test to determine if a client has myasthenia gravis, the client reports 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
The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury?
Avoid rubbing the eye on the affected side of the face
A neurologic deficit is best defined as a deficit of the:
Central and peripheral nervous systems with decreased, impaired, or absent functioning
A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment?
Decreased muscle spasms in the lower extremities
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. Which nursing action(s) would best address the report of headache? Select all that apply.
Dimming the lights & limiting noise
A client with paralysis is disturbed by spontaneous erections. Which nursing action may help the client?
Explain that it may occur when the bladder is full
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
Immediately
A client has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The client has just exhibited seizure activity for the first time. What is the nurse's priority response to this event?
Implement precautions to ensure the client's safety
The nurse in an extended care facility is planning the daily activities of a client with post-polio syndrome. The nurse recognizes the client will best benefit from physical therapy when it is scheduled at what time?
In the morning
The nurse is caring for a 55-year-old client on a rehabilitated unit following a cerebrovascular accident (CVA). The nurse is instructing on range of motion exercises when the client begins to cry. The client states they have always taken care of the family and does not want to be a burden. Which nursing diagnosis would the nurse add to the plan of care?
Ineffective Role Performance related to inability to function in family role
The nurse is providing postoperative care for a client who just underwent surgery to remove a metastatic intramedullary tumor. On postoperative day 3, the client states, "I am really looking forward to going running again, it had become too difficult because of the loss of feeling in my feet." Which should the nurse address in the client's care plan?
Knowledge deficit
A 73-year-old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. Assessment of the client shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this client?
Many symptoms can be the result of normal aging process
The nurse is caring for a client who has muscular dystrophy. When planning assistance with the client's ADLs, what goal should the nurse prioritize?
Maximizing the client's level of function
A client diagnosed with a brain tumor is exhibiting focal symptoms. Which assessment findings are the nurse likely to note? Select all that apply.
Muscle weakness, sensory loss, aphasia, visual changes
A client's spouse relates how the client reported a severe headache, and shortly after was unable to talk or move their right arm and leg. The spouse indicates the client has hypertension. What should be the focus of management during this phase?
Preventing further neurologic damage
During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client?
Prevention of joint contractures
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
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest?
Resting in an air-conditioned room whenever possible
A gerontologic nurse is advocating for diagnostic testing of an 81-year-old client who is experiencing personality changes. The nurse is aware of what factor that is known to affect the diagnosis and treatment of brain tumors in older adults?
The effects of brain tumors are often attributed to the cognitive effects of aging
