Exam 5

The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response?

"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."

What is myasthenia gravis?

-An autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue.

What is Paget's disease?

A disorder of localized rapid bone turnover most commonly affecting skull, femur, tibia, pelvic bones, and vertebrae

The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what issue?

A lower motor neuron lesion

What is ALS?

ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis.

What should the nurse use to prevent dislocation of hip during position changes or movement?

Abduction pillow

What is spasticity?

Abnormal increased muscle tone or stiffness of muscles

A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this patient?

Absolute bed rest in a quiet, nonstimulating environment

What are the expected findings of sympathetic nervous system?

Activated by stress, increase HR, BP, sweat, dilated pupils, and fight or flight response

Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

Administer benzodiazepines on a PRN basis.

What is athrography?

Arthrography is useful in identifying acute or chronic tears of the joint capsule or supporting ligaments of the knee, shoulder, ankle, hip, or waist. X-rays are used to diagnose bone fractures.

The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)?

Assess the patients eye opening and response to stimuli.

What are possible complications of skeletal traction?

Atelectasis, pneumonia, constipation, urinary stasis, and DVT

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?

Baclofen (Lioresal) is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury.

Positive sings of kernigs's and brudzinski are indicative of

Bacterial meningitis

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor?

Bending or lifting

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 being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus?

Clear mentation

What is straight traction?

Control spasm and immobilized injured part before surgery, easy to use but weight cannot exceed 6 pounds

What is a diagnostic used for osteoporosis?

DEXA

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

The homecare nurse is evaluating the musculoskeletal system of a geriatric client whose previous assessment was within normal limits. The nurse initiates a call to the health care provider and/or emergency services when which change is found?

Decreased right-sided muscle strength

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 trauma patient in the ICU has been declared brain dead. What diagnostic test is used in making the determination of brain death?

EEG

What are early manifestations of ALS?

Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

The nurse is admitting a client with multiple trauma to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg?

Elevated on pillows continuously for 24 to 48 hours.

After bone fracture, fibrocartilaginous callus formation normally occurs at the same time as which process?

Fibroblast migration

What are the four areas that occur in fracture healing?

Fracture healing occurs in four areas, including the bone marrow, bone cortex, periosteum, and the external soft tissue,

What is external fixator?

Frame and pins that are inserted perpendicular to the long axis bone

What is athrography?

Identify cause of unexplained joint pain and progression of joint disease

A nurse is planning the care of a 28-year-old client hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client?

In the morning, with frequent rest periods

A patient is having a "fightor flight response" after receiving bad news abou fis prognosis What affect will this have on the patient's sympathetic nervous system?

Increase secretion of sweat

What are medications used for Parkinson's disease?

Levodopa/carbidopa

The nurse is caring for a patient with an upper motor neuron lesion. What clinical manifestations should the nurse anticipate when planning the patient's neurologic assessment?

Loss of voluntary control of movement

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client?

MS is a progressive demyelinating disease of the nervous system.

What are the treatments of ICP?

Mannitol, restricting fluids, drain CSF, and reduce edema

What are advantages of skeletal traction?

More we can be applied, allows for movement, and facilitates independence

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

Neck flexion produces flexion of knees and hips

What is paralysis?

Paralysis is the loss of sensation and/or the ability to move a part of the body due to traumatic injury

The nurse is admitting a patient to the unit who is diagnosed with a lower motor neuron lesion. What entry in the patient's electronic record is most consistent with this diagnosis?

Patient demonstrates an absence of deep tendon reflexes.

What are complications of immobility?

Pneumonia, constipation, urinary stasis, and DVT

The patient in the ED has just had a diagnostic lumbar puncture. To reduce the incidence of a post-lumbar puncture headache, what is the nurse's most appropriate action?

Position the patient prone.

A patient with lower back pain is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should prioritize what action?

Positioning the patient with the head of the bed elevated 45 degrees

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.

The nurse is assessing the casted extremity of client. Which sign is indicative of infection?

Presence of a "hot spot" on the cast

The nurse should instruct the clients family to take which of the following actions first in the event of a seizure?

Protect clients head

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

What is traction?

Pulling force to maintain bone alignment during fracture healing

What are treatments for myasthenia gravis?

Pyridostigmine bromide( Mestinon) increased muscle strengthening, corticosteroid therapy, cytotoxic therapy, and thymectomy, and give tensilon

A patient scheduled for magnetic resonance imaging (MRI) has arrived at the radiology department. The nurse who prepares the patient for the MRI should prioritize which of the following actions?

Removing all metal-containing objects

What are some ways to decrease ICP?

Restful environment, mechanical ventilation, provide oxygen, elevate HOB at 30 degrees or more, and avoid valsalva maneuvers

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take?

Rewrap the residual limb with an elastic compression bandage.

What is an expected finding of increased ICP?

Rigid skull containing cranial content's & hyperthermia

What is Parkinson's disease?

Slowly progressing neurological movements disorder that leads to disability which results in loss of coordination and control of involuntary movement

What is balanced skeletal traction used for?

Stabilize fractures of the femur or pelvis

What is pelvic sling used for?

Stabilize pelvic fractures

What is osteomyelitis caused by?

Staphylococcus aureus

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding:

Temperature of 101.6°F (38.7°C) orally

What is a risk factor for osteoporosis?

The nurse should identify anorexia nervosa as a risk factor for osteoporosis.

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which the following findings should the nurse report to the provider?

Toes cold to the touch ------ The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch.

True or false. The nurse must never remove weights from skeletal traction unless life threatening situations occur?

True.

The nurse is developing a plan of care for a client with Guillain-Barre syndrome. Which of the following interventions should the nurse prioritize for this client?

Using the incentive spirometer as prescribed

What are treatments/medications for osteoporosis?

Vitamin D 1000mg-1200mg, regular weight bearing exercises, bisphosphonate, alendronate, Ibandronate

The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease?

Vocal paralysis

What are expected findings of GBS?

Weakness, paralysis, disorder of vagus nerve, decline of vital capacity, dysphagia, and voice changes

What is GBS?

acute inflammatory demyelinating polyneuropathy. Inflammatory disorder of peripheral nerves

The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication?

autonomic dysfunction

Which hormone inhibits bone reabsorption and increases calcium deposit in the bone?

calcitonin

Which is a neurovascular problem caused by pressure within a muscle area that increases to such an extent that microcirculation diminishes?

compartment syndrome

A patient is being given a medication that stimulates her parasympathetic system. Following administration of this medication, the nurse should anticipate what effect?

constricted pupils

Which is a circulatory indicator of peripheral neurovascular dysfunction?

cool skin

What is flaccidity?

decreased muscle tone, or weakening

What is dyskinesia?

difficulty performing voluntary movements, uncontrolled, involuntary movements

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 patient is admitted to the medical unit with an exacerbation of multiple sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?

function of hypoglossal nerve

The nurse is assessing the muscle tone of a client with cerebral palsy. Which description does the nurse determine to be an expected assessment of this client's muscle tone?

hypertonic

What is MRI used for?

non invasive technique that utilizes magnetic fields to produce an image of bone and soft tissue. Use to visualize torn muscle, ligaments, and cartilage

What is paresthesia?

numbness, tingling, pins and needles

What is paraplegia?

paralysis of both lower limbs

What is hemiplegia?

paralysis of one side of the body

The nurse is conducting a musculoskeletal assessment of a client in a nursing home. The client is unable to dorsiflex the right foot or extend the toes. The nurse evaluates this finding as an injury to which nerve?

peroneal

A client with a hip fracture asks the nurse why Buck's (extension) traction is being applied before surgery. The nurse provides a response based on which purpose of Buck's (extension) traction?

provides comfort by reducing muscle spasms and provides fracture immobilization

What is amputation?

removal of a body part by surgical procedure or trauma

The nurse is assessing a young client during an annual sports physical at school. The assessment reveals that the client has lateral curving of the spine. The nurse reports to the health care professional that the assessment revealed

scoliosis

An elderly patient is being discharged home. The patient lives alone and has atrophy of his olfactory organs. The nurse tells the patient's family that it is essential that the patient have what installed in the home?

smoke detector

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the cent states that he or she should report which early symptom of compartment syndrome:

Numbness and tingling in the fingers

What is ataxia?

Poor muscle coordination especially when voluntary movements are attempted. Difficulty with balance/coordination

What are some signs & symptoms of myasthenia gravis?

Double vision & Ptosis

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever or swelling to my health care provider."

The nurse has given a client instructions about crutch safety. Which client statementuctions abou crutch safety. Which cient statement indicates that the client understands the instructions? Select all that apply.

"I should not use someone else's crutches." "I need to remove any scatter rugs at home." "I can use crutch lips even when they are wet." "I need to have spare crutches and tips available."

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 suqgestive of Parkinson disease?

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

What is the parasympathetic nervous system?

"Rest and digest" Blood pressure/heart rate decrease, digestive increases, constricted pupil, increased peristaltic movement, and constricted bronchioles

What is fasciculation?

"involuntary ""twitch"" of muscle"

The nurse is conducting health screening for osteo-porosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes

A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?

Prepare to assist with intubation.

How often should the pin site be inspected for signs of infection/inflammation

Every 8 hours

What is Kernig's sign?

After flexing the hip and knee at 90 degree angles, pain and resistance are noted.

The nurse caring for an 80 year-old patient knows that she has a pre-existing history of dulled tactile sensation. The nurse should first consider what possible cause for this patient's diminished tactile sensation?

Age-related neurologic changes

When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?

Alteration in level of consciousness (LOC)

How to keep hip from dislocating when moving around?

Always keep patient legs abducted or apart , toes pointing up, hips must not flex more than 90 degrees, and turn patient to operative side only

What is a CT scan?

An x-ray, using specialized equipment, that takes cross-sectional pictures of the body. Use to visualize tumor, soft tissue injury, ligaments, and tendons

What is the care of pt with lumbar puncture?

Apply pressure to site to stop bleeding, have pt lie flat on bed for specific period of time, get plenty of rest, encourage oral fluids, monitor vital signs, and CSF leakage of fluids

The nurse is conducting a focused neurologic assessment. When assessing the patient's cranial nerve function, the nurse would include which of the following assessments?

Assessment of gag reflex

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.

What are complications related to ICP?

Brain stem herination, diabetes insipidis, and SIADH

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip athroplasty surgery?

Bucks traction

A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take?

Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. ----- The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client up, making sure to maintain proper alignment of the extremity.

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?

Hyperthermia

A client with diabetes mellitus has had a right Delow-knee amputation. Given the clients history of diabetes mellitus, which should the nurse spect-fically observe in the postoperative period:

I need to avoid getting the cast wet.

A client with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. Which of the following nursing diagnoses is most likely for a client with this condition?

Impaired verbal communication

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

What is goal of Parkinson's disease?

Promote effective communication, improve mobility, maintain independence, achieve ADL, monitor swallowing and maintain nutrition, and encourage exercise

A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications?

Pulmonary embolus ----- Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately.

What is EEG (Electroencephalogram)?

Records electrical activity of brain cells

A gerontologic nurse planning the neurologic assessment of an older adult is considering normal, age-related changes. Of what phenomenon should the nurse be aware?

Reduction in cerebral blood flow

Which cast care instructions should the nurse pro., vide to a client who just had a plaster cast applies to the right forearm? Select all that apply.

Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. 3 Keep the cast and extremity elevated.

What is a disadvantage of skeletal traction?

Risk for infection & increased discomfort

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding?

Serous drainage

What are expected findings of ICP?

Severe headaches, decreased LOC, vomiting, papilledema, slow to react , irritability, and dilated pupils

What is Brudzinski's sign?

Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.

What is the care for pin skeletal pins?

Site care should be done daily using Chlorexidine

A trauma patient was admitted to the ICU with a brain injury. The patient had a change in level of consciousness, increased vital signs, and became diaphoretic and agitated. The nurse should recognize which of the following syndromes as the most plausible cause of these symptoms?

Sympathetic storm

What is the plan of care for Parkinson's disease?

The goals for the client may include improving functional mobility, maintaining independence in ADLS, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, and developing positive coping mechanisms.

A patient is currently being stimulated by the parasympathetic nervous system. What effect will this nervous stimulation have on the patient's bladder?

The parasympathetic nervous system makes the bladder contract.

72-year-old man has been brought to his primary care provider by his daughter, who claims that he has been experiencing uncharacteristic lapses in memory. What principle should underlie the nurse's assessment and management of this patient?

Thorough assessment is necessary because changes in cognition are always considered to be pathologic.

What are signs & symptom of Parkinson's disease?

Tremors, bradykinesia, postural instability, muscle rigidity, and stooped posture

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

Uric acid level of 8 mg/dL

A nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take?

Use a hair dryer on a cool setting to blow air into the cast. ------ The nurse should provide relief for the report of itching by blowing cool air into the cast using a hair dryer on a cool setting or an empty 60-mL plunger syringe.

The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid?

Washing his face

A patient had a lumbar puncture performed at the outpatient clinic and the nurse has phoned the patient and family that evening. What does this phone call enable the nurse to determine?

Whether the patient has had any complications of the test

A patient is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the patient in preparation for this test?

You will need to lie still throughout the procedure.

What is electromyography?

a system for monitoring and recording the electrical activity in muscles

While reading a client's chart, the nurse notices that the client is documented to have paresthesia. The nurse plans care for a client with

abnormal sensations

A patient exhibiting an uncoordinated gait has presented at the clinic. Which of the following is the most plausible cause of this patient's health problem?

cerebellar dysfunction

What is the term for a rhythmic contraction of a muscle?

clonus

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect should the nurse assess this client?

dyskinesia (abnormal involuntary movements).

What are complications of amputation?

hemorrhage, infection, phantom limb pain, neuroma, flexion contracture

What is osteomyelitis?

infection of the bone

A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status?

level of consciousness

What is internal fixation?

pins, screws, nails, rod inserted surgically into the bone to hold together

What is Buck's traction?

skin traction to lower leg, immobilize fractures of proximal femur before fixation

What is hemiparesis?

weakness on one side of the body

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make?

"This type of pain usually decreases over time as the limb becomes less sensitive." ----- The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain.

The nurse is planning the care of a patient with Parkinson's disease. The nurse should be aware that treatment will focus on what pathophysiological phenomenon?

Decreased availability of dopamine

A client has sustained a closed racture and has jus had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Impaired tissue perfusion

What is athrocentesis?

Joint aspiration takes some of synovial fluid for examination and to relieve pain

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 client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family?

Risk for injury

What are the principles of tractions?

Skeletal contractions must never be interpreted, weight must not be removed, weight must hang freely, and patient must be in good body alignment with traction

The nurse is one of several persons who witnessed a vehicle hit a pedestrian at fairly low speed on a small street. The victim is dazed and tries to get up. The leg appears fractured. Which intervention should the nurse take?

Stay with the victim and encourage the person to remain still.

What is the cranial nerve XII responsible for?

The hypoglossal nerve is the 12th cranial nerve. It is responsible for movement of the tongue. Stick out tongue move side to side

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

hyperthermia

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. the nurse responds knowing that which would most likely result from this improper crutch measurement?

injury to the brachial plexus nerves

A patient is scheduled for a myelogram and the nurse explains to the patient that this is an invasive procedure, which assesses for any lesions in the spinal cord. The nurse should explain that the preparation is similar to which of the following neurologic tests?

lumbar puncture