Chapter 69 PrepU

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

Herpes simplex virus (HSV)

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?

Equipment to maintain infection control precautions

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?

The client will remain free of injury if a seizure does occur.

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Alternatively patch one eye every 2 hours

While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe?

Facial pain in the areas of the fifth cranial nerve

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

Multiple sclerosis

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 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?

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

Which of the following nursing interventions is appropriate for a patient with double vision in the right eye due to MS?

Apply an eye patch to the right eye.

Which of the following is the priority nursing intervention for a patient in myasthenic crisis?

Assessing respiratory effort

Bell's palsy is a disorder of which cranial nerve?

Facial (VII)

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

Headache and nuchal rigidity

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?

Initiate isolation precautions.

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?

Lung auscultation and measurement of vital capacity and tidal volume

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 (MS)

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

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

Overmedication

Which basic of client care, occurring during the acute phase, is most helpful in promoting the rehabilitation of a client following a debilitating cerebrovascular accident?

Prevention of joint contractures

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 a neurologic impairment reports to his home care nurse that he has been having problems with constipation. Which of the following foods might the nurse recommend?

Vegetables

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

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

controlling seizures and increased intracranial pressure.

The primary North American vector transmitting arthropod-borne virus encephalitis is the

mosquito

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

"You must avoid stress and extreme fatigue, because these can trigger a relapse."

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapherisis and explains this in which of the following statements?

Antibodies are removed from the plasma.

Which drug should be available to counteract the effect of Tensilon?

Atropine

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?

Bacteria

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intraveneously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds

An 89-year-old retired government clerk is being admitted to your rehabilitation hospital as a result of the tetraplegia caused by stroke. Her condition is stable, and after admission, she will begin physical and psychological therapy. An important part of your nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?

Maintain sufficient integument capillary pressure

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 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 the client reported a severe headache, shortly after he was unable to talk or move his right arm and leg. His wife indicates the client has hypertension. What should be your focus of management during this phase?

Preventing further neurologic damage

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?

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A 67-year-old firefighter now has a neurological defect and has been informed that he will be transferred to a nursing home because his son is unable to care for him at home. While receiving a bed bath, the patient yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?

Accept the patient's behavior and do not take it personally.