CNS & PNS Disorders

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. A) Cloudy cerebral spinal fluid B) Pain and stiffness of the extremities C) Purpura of hands and feet D) Low white blood cell (WBC) count E) Low red blood cell (RBC) count F) Low antidiuretic hormone (ADH) levels

A, C The CSF will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts .Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.

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

15 mg Step 1: 2.2 lb / 1 kg = 132 lb / X kg 132 lb = 2.2 X 60 kg = X Step 2: 1 kg / 0.25 mg = 60 kg / X mg 15 mg = X

The school nurse notes a 6-year-old running across the playground with his friends. The child stops in midstride, freezing for a few seconds. Then the child resumes his progress across the playground. The school nurse suspects what in this child? A) An absence seizure B) A myoclonic seizure C) A partial seizure D) A tonic-clonic seizure

A Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.

The client with Guillain-Barré syndrome is scheduled for plasmapheresis and is questioning how this process works. Which of the following statements by the nurse best describes plasmapheresis in the management of this syndrome? A) "Antibodies that triggered the autoimmune response are removed from your blood." B) "The blood removal allows for replacement of cleaner blood from a healthy person." C) "Blood transfusions are the gold standard for the treatment of this syndrome." D) "Plasma replacement dilutes the organisms that are causing the symptoms."

A Because GBS is believed to be an autoimmune disease, plasmapheresis (not blood transfusion) has emerged as a major treatment intervention. This process removes the blood, filters out the antibodies that trigger the autoimmune disease, and then returns the blood to the client. The blood removal is only a part of the process for filtering out antibodies and is not a dilution process

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop? A) Damage to the nerves that facilitate vision and hearing B) Damage to the vagal nerve C) Damage to the olfactory nerve D) Damage to the facial nerve

A Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve

You are caring for a client with an inoperable brain tumor. What is a major threat to this client? A) Increased ICP B) Decreased ICP C) Hypervolemia D) Hypovolemia

A Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased ICP is a major threat. In this scenario, there are no indications that volume either increased or decreased is an issue.

The home health nurse is caring for a client with Parkinson's disease. The nurse understands that the purpose of adding selegiline (Eldepryl) with carbidopa-levodopa (Sinemet) to the medication regime should result in which purpose? A) Slows the progression of the disease B) Replaces dopamine C) Relieves symptoms of dyskinesia D) Prevents side effects from Sinemet

A Selegiline (Eldepryl) increases dopaminergic activity and slows the progression of the disease. Carbidopa-levodopa (Sinemet) is a dopamine replacement drug. Anticholinergic drugs (such as Cogentin) are used to reduce the symptoms of dyskinesia and other side effects

A client, with a recent closed head injury, began experiencing partial (focal) seizures and asks the nurse to explain why this is happening. Which is the best response from the nurse? A) "It is not uncommon for seizure activity to occur after head trauma." B) "Only a portion of your brain has been irritated." C) "Generalized seizures are much worse and involve the entire brain." D) "Electrical impulses become confused and chaotic resulting in a seizure."

A The client wants a simple explanation to help alleviate fears and concerns. Explaining that seizures are common (or even normal) after head trauma can assist the client by decreasing fears and open the door for further teaching about the disruption of impulses and irritation in the brain due to the injury. Partial seizures involve a part of the brain that is irritated; this is factual but does not answer the question asked. Generalized seizures involve the entire brain from the onset and the electrical impulses are chaotic, but this information is not significant to the question asked by the client.

A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first? A) Elevate the head of the bed. B) Complete a head-to-toe assessment. C) Administer morning dose of anticonvulsant. D) Administer Percocet as ordered.

A The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF. Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing ICP. The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.

The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? A) Take small meals of nutrient and calorie-dense food. B) Increase the intake of calcium and proteins. C) Include additional servings of fruits and raw vegetables. D) Include fish, liver, and chicken in diet.

A To help a client with trigeminal neuralgia who suffers pain in the jaws meet his or her nutritional needs, the nurse should offer small meals of soft consistency. Foods may be pureed to minimize jaw movements when eating. There is no need for the client to increase the intake of fruits and raw vegetables, calcium, or proteins during trigeminal neuralgia. In addition, an increased intake of fruits and raw vegetables requires excessive chewing, potentially increasing the incidence of jaw pain. The nurse should avoid offering meat and fish in the diet because they also require excessive chewing by the client.

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? A) Decreased pulse rate, respirations of 20 breaths/minute B) Increased pulse rate, adventitious breath sounds C) Increased pulse rate, respirations of 16 breaths/minute D) Decreased pulse rate, abdominal breathin

B An increased pulse rate above baseline with adventitious breath sounds indicate compromised respirations and signal a need for airway clearance. A decrease in pulse rate is not indicative of airway obstruction. An increase of pulse rate with slight elevation of respirations (16 breaths/minute) is not significant for suctioning unless findings suggest otherwise.

Following a motorcycle accident, a client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A) Blood pressure 100/60 mm Hg B) Lethargy C) Nausea D) Periorbital edema

B Decreasing level of consciousness is one of the earliest signs of increased ICP. Without a baseline for the BP, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Perioribital edema is more suggestive of fluid overload than ICP.

The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action? A) Assess client's reaction to new medication schedule. B) Administer medications at exact intervals ordered. C) Document medication given and dose. D) Give client plenty of fluids with medications.

B He or she must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.

A client, who was adopted at birth, recently discovers that Huntington's disease is prevalent in the biological family history. How can the nurse best assist the client in dealing with personal fears? A) Provide information of the progression of the disease. B) Encourage client to verbalize fears. C) Explain that inherited risk is 50%. D) Offer genetic testing.

B Huntington's disease is a hereditary disorder of the CNS that is progressive and has no cure. Being able to verbalize fears and concerns that are real can be therapeutic for the client. Providing information about genetic testing, inherited risk, and progression of the disease will not alleviate fears and can be postponed until the client is ready for this information.

You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should you keep always ready at the bedside? A) Nebulizer and thermometer B) Intubation tray and suction apparatus C) Blood pressure apparatus D) Incentive spirometer

B Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature

Which of the following teaching points is a priority in the management of symptoms for a client with Bell's palsy? A) Avoid stimuli that trigger pain. B) Use ophthalmic lubricant and protect the eye. C) Encourage semiannual dental exams. D) Complete the course of antibiotics as prescribed

B The VII cranial nerve supplies muscles to the face. In Bell's palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.

The spouse of a client with terminal brain cancer asks the nurse about hospice. Which statement by the nurse best describes hospice care? A) "Hospice care uses a team approach and provides complete care." B) "Clients and families are the focus of hospice care." C) "The physician coordinates all the care delivered." D) "All hospice clients die at home."

B The most important component of hospice care is the focus that is placed on the care of the client as well as the family. Hospice does take a team approach and coordinates care through the hospice physician, but these are not the focus. Not all hospice clients wish to die at home.

The client is switched to a different dose of carbidopa-levodopa (Sinemet). Which nursing assessment is primary during this time of medication change? A) Observe for jaundice. B) Assess for euphoria. C) Monitor vital sign fluctuation. D) Monitor for elevation of glucose levels

C Adverse effects of dopamine replacement drugs include cardiac dysrhythmias, hypotension, muscle cramps, and GI distress. Vital signs should be monitored during periods of medication adjustment, and changes such as orthostatic hypotension and arrhythmias/palpitations should be reported. The nurse should monitor the liver enzymes and BUN, but jaundice should not occur. During changes in dopamine levels, the client may exhibit signs of paranoia or suicidal ideation not euphoria. Blood sugar levels are not affected by dopamine replacement drugs.

Following a generalized seizure in a client, which nursing assessment is a priority for detailing the event? A) Seizure began at 1300 hours. B) The client cried out before the seizure began. C) Seizure was 1 minute in duration including tonic-clonic activity. D) Sleeping quietly after the seizure

C Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and their skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity

A client is admitted for scheduled gamma-knife radiosurgery, in the treatment of a brain tumor. Which nursing measure is primary in the postsurgical care of this client? A) Assessing skull dressing for excess drainage B) Time, distance, and shielding against radiation C) Assess neurological findings. D) Maintain airway via artificial ventilation.

C Gamma-knife radiosurgery is a non-invasive alternative for treating tumors within the brain. The nurse would be responsible for completing a neurological assessment on the client and providing comfort measures as needed. There is no incision on the skull, and no risk for radiation exposure to the nurse. The procedure eliminates surgical and anesthesia complications and does not result in use of a ventilator or artificial airway maintenance.

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? A) Impaired Home Maintenance B) Altered Nutrition C) Hopelessness D) Disturbed Sleep Pattern

C Huntington's disease is an inherited disease that has progressive physical, emotional, and mental involvement. There is no cure or course of treatment to preserve or prevent disease progression. Death is eminent. This client feels hopeless and helpless and sees no alternatives or choices available and is unable or unwilling to move forward with living. Impaired Home Maintenance is not significant. Altered Nutrition and Disturbed Sleep Patterns are apparent, but unless the client is able to mobilize energy to move forward, these problems cannot be resolved

A client with increased intracranial pressure is receiving mannitol (Osmitrol) via intravenous infusion. Which assessment finding is most important in determining the effectiveness of this treatment? A) Blood pressure is rising. B) Level of consciousness is improving. C) Urine output is increased. D) Hyperpyrexia is resolving.

C Mannitol is a hypertonic solution that helps to pull fluid from the cells into the vascular system where the kidneys can eliminate as urine. The blood pressure should lower as the fluid volume is depleted. Level of consciousness may improve as the ICP is lowered, but the use of mannitol is for diuresis. Resolving fever is not significant with the use of mannitol.

The client presents to the walk-in clinic with fever, nuchal rigidity, and headache. Which of the following assessment findings would be most significant in the diagnosis of this client? A) Change in level of consciousness B) Vomiting C) Vector bites D) Seizures

C Possible exposure to mosquito bites can be beneficial in the diagnosing of encephalitis secondary to West Nile virus. Change in LOC, vomiting, and seizures are all symptoms of increased ICP and due not assist in the differentiating of cause, diagnosis, or establishing nursing care

A client diagnosed with Huntington's disease has developed severe depression. What would be most important for the nurse to assess for? A) Loss of bowel and bladder control B) Choreiform movements C) Suicidal ideations D) Emotional apathy

C Severe depression is common and can lead to suicide, so it is most important for the nurse to assess for suicidal ideations. Symptoms of Huntington's disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these symptoms is appropriate but not as important as assessing for suicidal ideations.

The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is important for the nurse to do with this client? A) Optimizing nutrition B) Managing muscle weakness C) Explaining hospice care and services D) Offering family support group

C The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.

A client you are caring for experiences a seizure. What would be a priority nursing action? A) Restrain the client during the seizure. B) Insert a tongue blade between the teeth. C) Protect the client from injury. D) Suction the mouth during the convulsion.

C The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.

A 30-year-old was diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse? A) "I will have progressive muscle weakness." B) "I will lose strength in my arms." C) "My children are at greater risk to develop this disease." D) "I need to remain active for as long as possible."

C There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications

A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse? A) Insert an airway or bite block. B) Manually restrain the extremities. C) Turn client to side-lying position. D) Monitor vital signs.

C When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take B/P is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase

A client is receiving baclofen (Lioresal) for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? A) Sleep pattern B) Mood and affect C) Appetite D) Muscle spasms

D Baclofen (Lioresal) is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, Lioresal may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client? A) Epilepsy B) Trigeminal neuralgia C) Hypostatic pneumonia D) Brain tumor

D Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. Choices A, B, and C are not associated with papilledema or constant headache.

The nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began? A) Shortness of breath B) Sensitivity to bright light C) Muscle spasms D) Drooping eyelids

D Ptosis is the most common manifestation of myasthenia gravis. Muscle weakness varies depending on the muscles affected. Shortness of breath and respiratory distress occurs later as the disease progresses. Muscle spasms are more likely in multiple sclerosis. Photophobia is not significant in myasthenia gravis

Which topic is most important for the nurse to include in the teaching plan for a client newly diagnosed with Parkinson's disease? A) Involvement with diversion activities B) Enhancement of the immune system C) Establishing balanced nutrition D) Maintaining a safe environment

D The primary focus in caring for Parkinson's disease is on maintaining a safe environment. Parkinson's disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A) Dextrose 5% in water (D5W) B) Half-normal saline (0.45% NSS) C) One-third normal saline (0.33% NSS) D) Mannitol (Osmitrol)

D With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. A) Stiff neck B) Generalized pain C) Glasgow Coma Scale of 15 D) Elevated systolic blood pressure E) Brisk pupil response F) Wide pulse pressure

D, F Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.