LeMone Ch. 44
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). The nurse should realize that the prognosis for this patient is: 1. poor; the disease rapidly progresses and is fatal. 2. good; the disease will progress over many years but the quality of life will be good. 3. good; the disease progresses rapidly but can be halted by drug therapy. 4. excellent; the disease will progress slowly and can be controlled by medication.
Correct Answer: 1 Rationale: ALS is rapidly progressive and fatal, characterized by weakness and wasting of muscles that are under voluntary control, without any accompanying sensory changes. The prognosis is not good. The quality of life will not be good. A new drug, riluzole (Rilutek), is now available in the treatment of the disease but will not halt it. Death usually occurs due to respiratory failure.
An adult patient with Bell palsy asks if the facial paralysis and distortion will go away. How should the nurse response to this patient? 1. "Most people recover completely within a few weeks to a few months." 2. "Everyone recovers from Bell palsy in three to five weeks." 3. "Most people have permanent facial paralysis on both sides of the face." 4. "Most people have permanent facial paralysis on one side of the face."
Correct Answer: 1 Rationale: About 80% of people recover completely from Bell palsy within a few weeks to a few months. Recovery can take longer than 3 to 5 weeks. The facial paralysis will resolve. There will not be permanent paralysis on one or both sides of the face.
The nurse is reviewing medication orders for a patient with multiple sclerosis (MS). What medication should the nurse expect to be prescribed for this patient? 1. adrenocorticotropic hormone (ACTH) 2. meperidine (Demerol) 3. monoamine oxidase (MAO) inhibitors 4. rivastigmine tartrate (Exelon)
Correct Answer: 1 Rationale: Adrenocorticotropic hormone (ACTH) decreases inflammation and suppresses the immune system. Meperidine (Demerol) is a narcotic analgesic and would not be used to treat MS. MAO inhibitors are used to treat depression. Rivastigmine tartrate (Exelon) is used in the treatment of Alzheimer disease.
The nurse is completing teaching to a patient with a new diagnosis of Bell palsy. What should be a priority focus of this teaching? 1. eye care 2. promoting effective swallowing 3. pain management 4. improving muscle strength in the upper extremity
Correct Answer: 1 Rationale: Eye care should be addressed since manifestations of Bell palsy include paralysis of the upper eyelid with loss of the corneal reflex and increased tearing on the affected side. Chewing, not swallowing, may be difficult due to unilateral paralysis of facial muscles. Pain may precede the onset of facial paralysis but is not an issue during the course of the disease. Upper extremity muscles are not affected.
The nurse is completing discharge teaching to a patient with a new diagnosis of multiple sclerosis (MS). What does the nurse recommend about diet? 1. Focus on maintaining a weight as close as possible to what is recommended for the patient's height and weight. 2. Increase fats and lower carbohydrates. 3. Include foods that are easy to swallow since dysphagia is a problem seen in the early stages of the disease. 4. Basically remain the same, as there are no nutritional changes in the MS patient.
Correct Answer: 1 Rationale: It is recommended that the MS patient should ideally maintain a weight as close as possible to what is recommended for the patient's height and weight. There is no reason for the patient to increase fat intake and decrease carbohydrates. Dysphagia is seen in the later stages of the disease. Dysphagia is a common problem as MS progresses. At that point, the diet should be adapted to accommodate changes in the patient's ability to chew and swallow, and collaboration with a dietitian will be important.
The nurse is reviewing laboratory reports for a patient. What health problem should the nurse realize this patient is experiencing? Lab Results Edrophonium chloride (Tensilon) = positive (for 4.5 minutes) Single-fiber electromyography = delayed nerve transmission Serum acetylcholine receptor antibodies = elevated levels 1. myasthenia gravis 2. Parkinson disease 3. amyotrophic lateral sclerosis (ALS) 4. Guillain-Barré syndrome (GBS)
Correct Answer: 1 Rationale: Laboratory results consistent with a diagnosis of myasthenia gravis include a positive edrophonium chloride (Tensilon) test, delayed nerve transmission during electromyography, and elevated levels of serum acetylcholine receptor antibodies. There are no diagnostic tests for Parkinson disease, amyotrophic lateral sclerosis, or Guillain-Barré syndrome.
A patient comes to the clinic with complaints of blurred vision and muscle spasms that come and go, which have been occurring over the past several months. The patient is scheduled for an MRI and lumbar puncture with examination of the CSF. Which important patient history information is important for the nurse to note? Select all that apply. 1. The patient is a 22-year-old woman from Canada. 2. The patient is Caucasian and lives in the United States. 3. The patient has a family history of epilepsy. 4. The patient has been depressed. 5. The patient's father had Parkinson disease.
Correct Answer: 1, 2 Rationale: Women are affected by MS two times more often than men. Onset is typically between the ages of 20 and 40. High rates of multiple sclerosis occur in regions of northern Europe, the United States, and Canada. Family history of epilepsy, Parkinson disease, and depression are important items of the patient's history but do not support a diagnosis of MS.
The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the primary focus of care for this patient? 1. respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication 2. providing gastrostomy feedings as soon as possible so as to build up muscle mass when motor functions return 3. pain management and active range-of-motion (ROM) exercises 4. giving immunosuppressants
Correct Answer: 1 Rationale: Manifestations of ALS include loss of both upper and motor neurons, resulting in loss of the muscles of respiration and swallowing. Atrophy of the tongue and facial muscles results in swallowing difficulty and the inability to communicate. Gastrostomy feedings may be needed as the disorder progresses and muscle function is permanently lost. Pain management and immunosuppressants are not part of the treatment of ALS. Active ROM exercises are instituted only if the patient is able, then passive ROM exercises are initiated to stimulate circulation.
A patient's spouse states, "I've noticed that my spouse doesn't sleep well anymore and sometimes can't find the right words." What is the most appropriate response by the nurse? 1. "How long have you noticed these changes?" 2. "Does anyone in your family have Alzheimer disease?" 3. "These are common changes associated with age." 4. "Do you think your spouse is depressed?"
Correct Answer: 1 Rationale: Many older adults experience mild problems with memory, but do not have AD. Careful evaluation of the older adult is done in order to avoid misdiagnosing dementia in these cases. Family history is important to note, but a diagnosis of Alzheimer disease is made by eliminating all physiological factors first. Assuming these are age-related changes is inappropriate. Although depression is underdiagnosed in the elderly patient and is sometimes mistaken for Alzheimer disease, a thorough evaluation must be made before making a diagnosis.
A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis (MS). What should the nurse identify as a priority for self-care? 1. Apply for nursing positions that are less stressful and demanding. 2. Work as hard as possible now because it may not be possible later. 3. Continue to work as scheduled without making changes. 4. Leave employment as a nurse due to the need for complete bed rest.
Correct Answer: 1 Rationale: Multiple sclerosis (MS) is progressive and will be negatively affected by working long hours and enduring stressful shifts. It is important for this patient to plan a schedule that is less demanding and move now to a work environment that is less stressful for adapting to life with MS. There is no way of knowing how the disease will progress. Maintaining a routine schedule might be difficult because of fatigue. There is no reason for the nurse to quit working because complete bed rest is not indicated.
A patient with Parkinson disease is demonstrating bradykinesia. The nurse will likely observe which action in this patient? 1. slowed or delayed movements 2. increased spontaneous movements 3. active exercise and high energy 4. very slow talk
Correct Answer: 1 Rationale: Parkinson disease creates the slowed or delayed movements typical of bradykinesia. It does not create an increase in spontaneous movements that occur more slowly. High energy and active exercise is difficult for the patient with Parkinson disease. Patients with Parkinson disease do talk slowly, but the term bradykinesia refers to movement.
The nurse notes that a patient with Parkinson disease is experiencing tremors and muscle rigidity. Which medication should the nurse expect to be prescribed for these manifestations? 1. propranolol (Inderal) 2. acetaminophen (Tylenol) 3. meperidine (Demerol) 4. nitroglycerin (Nitro-bid)
Correct Answer: 1 Rationale: Propranolol (Inderal) can be used to treat tremors. Acetaminophen (Tylenol), meperidine (Demerol), and nitroglycerin (Nitro-bid) do not affect tremors.
A patient with Guillain-Barré syndrome asks if recovery is possible. What should the nurse respond to this patient? 1. "Recovery will be slow, but your chance of getting better is good." 2. "Only time and prayer will tell." 3. "Do not worry about that right now." 4. "Recovery is not likely."
Correct Answer: 1 Rationale: Recovery is likely, but it can take weeks to years for recovery. Nontherapeutic responses do not address the patient's concerns.
The nurse is reviewing medication orders for a patient with Alzheimer disease. Which medication should the nurse expect to be prescribed for this patient? 1. rivastigmine tartrate (Exelon) 2. adrenocorticotropic hormone (ACTH) 3. meperidine (Demerol) 4. acetaminophen (Tylenol)
Correct Answer: 1 Rationale: Rivastigmine tartrate (Exelon) is used to improve the ability to carry out activities of daily living. It decreases agitation and delusions and improves cognitive function. Adrenocorticotropic hormone (ACTH) is a natural hormone, but it has no known ability to treat Alzheimer disease. Meperidine (Demerol) is a narcotic used to treat moderate to severe pain and would not be indicated in treatment of Alzheimer disease.
The husband of a patient with Alzheimer disease (AD) asks the nurse to explain sundowning. How should the nurse respond to this question? 1. "Your wife can become more agitated, disoriented to time, and wander during the afternoon or early evening." 2. "Your wife's eyes will appear more downcast and the lids will droop." 3. "Repetition of words or phrases occurs more frequently." 4. "The ability to perform simple tasks is lost."
Correct Answer: 1 Rationale: Sundowning can be decreased by providing quiet activities, such as listening to favorite music in the afternoon or early evening. Downcast eyes and drooping eyelids is not a description of sundowning. Echolalia is the term for frequent repetition of words or phrases. Loss of the ability to perform simple tasks is common to stage 2 of AD.
A patient is diagnosed with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the priority nursing activity for this patient? 1. Support the patient and family to meet physical and psychosocial needs. 2. Monitor for infection. 3. Assist the patient to avoid complications. 4. Assist the patient to adapt to the disease.
Correct Answer: 1 Rationale: Support for the patient and family should receive the highest priority for nursing intervention. It is also important to monitor for infection, and assist the patient and family to avoid complications and adapt to the disease, but these are not as important as supporting the patient and family to meet physical and psychosocial needs.
A patient with Parkinson disease asks the nurse what an "on-off" problem means with medications. What should the nurse explain to the patient? 1. "The 'on' times will be when your symptoms are under control; the 'off' times are when you will have increased problems with symptom management." 2. "There will be times when you are depressed (off) and when you are happy (on)." 3. "You will have to take breaks from this medicine by stopping (off) and starting it (on) again, so you don't build up a tolerance to it." 4. "I'm not a pharmacist, so I shouldn't be answering this question."
Correct Answer: 1 Rationale: The "on-off" phenomenon occurs after the patient takes levodopa for several years; this phenomenon is characterized by unexpected dyskinesias (abnormal movements) and lack of symptom control. The "on-off" phenomenon has nothing to do with depressive episodes and the medication for Parkinson disease should not be started and stopped. A nurse should be able to answer questions about the patient's medications, or at least attempt to find the answer if it is not known.
A test that is used to diagnose myasthenia gravis (MG) is ordered by the physician. Because the test involves an injection of a drug that makes muscle strength improve for about five minutes, the nurse realizes that this test most likely is: 1. the Tensilon test. 2. a computed tomography (CT) scan of the legs. 3. a nerve stimulation study. 4. analysis of antiacetylcholine receptor antibodies.
Correct Answer: 1 Rationale: The Tensilon test produces a five-minute increase in muscle strength. A computed tomography (CT) scan of the legs is not indicated for this patient. The nerve stimulation study and the analysis of antiacetylcholine receptor antibodies are tests that can be done to help diagnose MG, but do not require a drug injection.
A patient complains of periods of confusion and forgetfulness at times, and reports clear thought process at most times of the day. The symptoms have been gradually worsening. What should the nurse say in response to this patient? 1. "Have you started any new medications since the symptoms began?" 2. "You probably have nothing to worry about; it's most likely stress-related." 3. "Everybody has a few problems with memory as they get older." 4. "You should probably have an MRI of your brain."
Correct Answer: 1 Rationale: The diagnosis of Alzheimer disease requires the documented presence of dementia, onset between 40 and 90 years, no loss of consciousness, and absence of systemic or brain disorders that could cause mental changes. Side effects of medication should also be ruled out as a possible cause of the symptoms. A nurse should never discount the patient's concerns and memory loss with confusion, and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.
The nurse is assessing cranial nerve function in the patient recovering from percutaneous rhizotomy of the facial nerve. What technique should the nurse use when making this assessment? 1. Ask the patient to blow out the cheeks, wrinkle the forehead, frown, wink, and close both eyes tightly. 2. Have the patient touch the index finger to the nose with eyes open, and then repeat the movement with eyes closed. 3. Ask the patient to shrug the shoulders, and then repeat the movement when resistance is applied. 4. Have the patient turn the head to the left, then the right, and touch the ear to the shoulder on the left and right sides.
Correct Answer: 1 Rationale: The facial nerve is assessed by asking the patient to blow out the cheeks, wrinkle the forehead, frown, wink, and close both eyes tightly. The other options assess coordination, the trapezius muscle and muscle strength, and motion of the neck.
A patient with stage 2 Alzheimer disease becomes very agitated in the evenings. What would be an appropriate nursing intervention for the nurse to use for this patient? 1. playing soft music in the patient's room 2. use of anti-anxiety medications or tranquilizers 3. moving the patient to an area of activity to provide distraction 4. recommending the patient be moved to a more secure environment
Correct Answer: 1 Rationale: The use of music is considered an alternative therapy helpful in the treatment of Alzheimer disease. Though the use of anti-anxiety agents and tranquilizers might be helpful, this is not a true nursing intervention. Patients with Alzheimer disease should be removed from situations that are causing increased anxiety, such as noisy activities involving large groups. High-stimulus situations may increase anxious feelings and agitation. If the patient were not a danger to him- or herself or others, there would be no indication that a more secure environment would be the best intervention.
A patient comes to the clinic complaining of excruciating pain on one side of the face. What should the nurse suspect is occurring with this patient? 1. trigeminal neuralgia 2. Parkinson disease 3. Bell palsy 4. myasthenia gravis
Correct Answer: 1 Rationale: Trigeminal neuralgia is characterized by unilateral excruciating facial pain. This symptom is not associated with Parkinson disease, Bell palsy, or myasthenia gravis.
The nurse is caring for a patient with trigeminal neuralgia. What should the nurse expect the treatment focus to be for this health problem? 1. drugs such as tricyclic anticonvulsants or surgically severing the nerve root (rhizotomy) 2. antiviral drugs such as acyclovir and physical therapy 3. respiratory support and NSAIDs 4. physical therapy and warm, moist packs to the affected area
Correct Answer: 1 Rationale: Trigeminal neuralgia is treated by a pharmacologic approach to pain control by prescribing tricyclic anticonvulsants such as carbamazepine (Tegretol) or rhizotomy, which is surgically severing the nerve root. Antiviral drugs and physical therapy are treatments for Bell palsy. Respiratory support, NSAIDs, physical therapy, and warm, moist packs to the affected area are not appropriate treatments.
A home health nurse visits a stage 4 Alzheimer disease patient who lives at home with a spouse. In order to meet the needs of the spouse, what should the nurse suggest? 1. finding respite care to come into the home several days a week 2. making arrangements for the patient to visit the local senior citizens' center in the afternoon 3. providing the patient a list of daily activities to complete 4. finding placement in a long-term care facility
Correct Answer: 1 Stage 4 patients generally exhibit decreased capacity to perform complex tasks (such as buying groceries or paying bills), a reduced memory for personal history, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the patient's care. Since the stage 4 patient does not adapt well to changes in his or her environment, it would be best to have someone come into the home, rather than to have the patient go out. An outing or a list of activities would be better suited for the patient in stage 1. Recommending placement in long-term care might be premature and is not up to the nurse.
The nurse is caring for a patient with Guillain-Barré syndrome. Which medication should the nurse expect to provide to this patient? Select all that apply. 1. antibiotics for urinary tract or respiratory infections 2. morphine for muscle pain 3. anticoagulants to prevent DVTs and pulmonary emboli 4. anticonvulsants to prevent seizures 5. anticholinesterase inhibitors to improve muscle strength
Correct Answer: 1, 2, 3 Rationale: Medications may be prescribed to provide support or prophylaxis, or to combat concurrent problems in the patient with Guillain-Barré syndrome. These include antibiotics for urinary tract or respiratory infections, morphine for muscle pain and anticoagulants to prevent DVTs and pulmonary emboli. Anticonvulsants and anticholinesterase inhibitors are not used in the treatment of Guillain-Barré syndrome.
The nurse is concerned that a patient recovering from a thymectomy is developing a pneumothorax. What did the nurse assess to cause this concern?Select all that apply. 1. shortness of breath 2. decreased breath sounds 3. sudden onset of chest pain 4. coughing pink-tinged mucous 5. pain level 5 on a scale from 0 to 10
Correct Answer: 1, 2, 3 Rationale: Patients with a thoracotomy and sternal split procedure will require care of the anterior chest tube. Observe for complications, such as pneumothorax. Air may enter the thoracic cavity causing sudden chest pain, dyspnea, and decreased breath sounds. Pink-tinged mucous is not an indication of a hemothorax. Pain level 5 on a scale from 0 to 10 would be expected after a thoracotomy.
The nurse is preparing to care for a patient with Alzheimer disease. What should the nurse identify as common signs of this disorder? Select all Apply 1. poor or decreased judgment 2. declining job skills 3. inability to be comfortable in social situations 4. obsession with organization 5. focused on abstract thoughts
Correct Answer: 1, 2, 3 Rationale: Poor or decreased judgment and having performance issues in social and work settings that are noticeable to others are warning signs of AD. Obsession with organization and a focus on abstract thoughts are not usually associated with Alzheimer disease.
The nurse is preparing a patient for plasmapheresis. In which order should the nurse complete the following actions? Click and drag the options below to move them up or down. Choice 1. Check with physician about holding medications. Choice 2. Assess vital signs and weight. Choice 3. Verify blood type and crossmatch for replacement blood products. Choice 4. Assess for dizziness or hypotension. Choice 5. Assess intravenous port for bruising. Choice 6. Reevaluate laboratory data, especially CBC, platelet count, and clotting times.
Correct Answer: 1, 2, 3, 4, 5, 6 Rationale: Check with the physician about holding medications until after the procedure. Medications may be removed from the body as an incidental part of the plasmapheresis process. Assess vital signs and weight. Baseline parameters are necessary to evaluate for fluid imbalances and response to therapy. Check blood type and crossmatch for replacement blood products. Hypersensitivity reactions can occur, and close monitoring is important. During the procedure, assess for dizziness or hypotension due to hypovolemia, which can occur. Hypovolemia is a complication of plasma exchange, especially during the procedure when up to 15% of the patient's blood volume is in the cell separator. After the procedure, assess the intravenous port for signs of bruising. The site of vascular access is at risk for complications and must be routinely and carefully assessed for bleeding or hematoma formation. Reevaluate laboratory data since anticoagulation is part of the procedure. The cell-separating process can damage cells; anticoagulation is part of the procedure.
A patient with myasthenia gravis is prescribed pyridostigmine (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report? Select all that apply. 1. increased weakness 2. problems with increased drooling 3. orthostatic hypotension 4. headache 5. increased difficulty swallowing
Correct Answer: 1, 2, 3, 5 Rationale: An overdose or underdose of anticholinesterase drugs can lead to a myasthenic or cholinergic crisis. The goal of pharmacological therapy is to increase muscle tone; weakness after taking the medication should be reported as soon as possible to offset a medical emergency. Manifestations of myasthenic crisis include increased difficulty swallowing and chewing, muscle weakness, fast heartbeat and restlessness. Increased drooling and lowering of blood pressure should be reported. Headache does not need to be reported.
The nurse is caring for a patient recovering from a percutaneous rhizotomy for trigeminal neuralgia. What techniques should the nurse use to assess this patient for adverse effects from the procedure? Select all that apply. 1. clench the teeth 2. touch the cornea with a cotton wisp 3. stick out the tongue 4. place sugar on the front of the patient's tongue 5. move the eyes through the cardinal positions of vision
Correct Answer: 1, 2, 4, 5 Rationale: Assess the motor portion of the trigeminal nerve by asking the patient to clench the teeth while the tightness of the contracted masseter and temporal muscles is palpated. Loss of motor function is indicated by loss of bulk and tightness of these muscles. Assess the corneal reflex by lightly touching the cornea with a wisp of cotton. If the reflex is intact, the patient will blink. Severing the ophthalmic division of the trigeminal nerve destroys the corneal reflex and leaves the cornea at risk for dryness and injury. Sticking out the tongue assesses the function of the hypoglossal nerve and not the trigeminal nerve. Test taste by placing bitter, salty, and sweet substances on the anterior portion of the tongue. The facial nerve also innervates the anterior two-thirds of the tongue. Assess the function of the oculomotor muscles by asking the patient to follow a finger through the cardinal positions of vision. The eyes should move together; alterations in movement indicate an abnormal response.
A patient is prescribed tetrabenazine (Xenazine) for treatment of chorea caused by Huntington disease. What should the nurse emphasize when teaching the patient and family about this medication? Select all that apply. 1. Do not take with levodopa. 2. Avoid overexposure to heat. 3. Report any suicidal thoughts. 4. Be alert for signs of depression. 5. Have routine liver function tests completed.
Correct Answer: 1, 3, 4 Rationale: Tetrabenazine shows the most improvement in treating the chorea of Huntington disease. The drug may cause depression and risk of suicide; patients and caregivers should immediately stop the drug and notify the healthcare provider if manifestations of depression are observed. It increases the effects of, and should not be taken in combination with, Levodopa (for Parkinson disease). Overexposure to heat is a potential adverse effect of medications used to treat Parkinson disease. Riluzole is associated with the risk of elevated liver enzymes.
A patient who is newly diagnosed with Huntington disease asks the nurse whether this disorder can be passed on to future children. What should the nurse say in answer to this patient? Select all that apply. 1. "There may be genetic concerns that should be discussed with the physician." 2. "Children will not be affected by the disease." 3. "The disease is passed on genetically in 75% of offspring." 4. "Each child will have a 50% chance of inheriting the gene." 5. "Genetic testing is can determine who has the disease.
Correct Answer: 1, 4, 5 Rationale: Huntington disease (HD) is a progressive, degenerative, inherited neurologic disease. Children have a 50% chance of inheriting the disease. DNA testing for the marker on chromosome 4 can determine whether the person is a carrier of the disease before beginning to exhibit manifestations
The nurse is assessing a patient with Guillain-Barré syndrome. What should the nurse expect to assess in this patient? Select all that apply. 1. increased muscular weakness 2. increased lower extremity edema 3. increased confusion 4. increased intolerance to light 5. decreased deep tendon reflexes
Correct Answer: 1, 5 Rationale: As Guillain-Barré develops, the patient will, experience muscle weakness with paralysis from altered nerve conduction (motor nerves become demyelinated). One manifestations of the acute stage is decreased deep tendon reflexes. Increased lower extremity edema, confusion, and intolerance to light are not manifestations of this disorder.
The nurse suspects that a patient has Parkinson disease. What did the nurse assess as early signs of this neurologic disease? Select all that apply. 1. fatigue 2. cogwheel rigidity 3. being "frozen" 4. bilateral involvement 5. a slight a rhythmic hand tremor
Correct Answer: 1, 5 Rationale: Parkinson disease begins with subtle manifestations. Patients may complain of feeling tired and may move more slowly. Tremor at rest is usually the first manifestation experienced in PD. Cogwheel rigidity, being "frozen," and bilateral involvement are later manifestations of PD.
The nurse is having a conversation with an older adult with Parkinson disease. What speech patterns would this patient most likely exhibit during conversation with the nurse? Select all that apply. 1. a low-pitched monotone voice 2. bubbly, spirited discussion 3. jumbled words that do not make sense 4. angry, loud talk 5. slurring and poor articulation of words
Correct Answer: 1, 5 Rationale: Voice amplitude and vocal articulation is affected by the neuromuscular effects of Parkinson disease. The voice becomes very monotonous with progression of the disease; patients will exhibit slowed speaking patterns and will have difficulty articulating clearly. Patients will need to be reminded to speak loudly. Muscular ability may make communication difficult, but the patient will retain cognitive ability, so communication should make sense. The patient with Parkinson disease will not have a bubbly spirited discussion, sound angry, or have a loud voice.
After returning from a plasmapheresis treatment, the nurse suspects that a patient with myasthenia gravis is demonstrating signs of electrolyte imbalances. What did the patient demonstrate to confirm the nurse's suspicion? Select all that apply. 1. sluggish bowel sounds 2. heart rate 92 and irregular 3. onset of circumoral tingling 4. blood pressure 148/90 mmHg 5. bilateral calf cramping
Correct Answer: 2, 3, 5 Rationale: Observe for circumoral tingling if calcium levels are low and cardiac dysrhythmias and leg cramps if potassium levels are low. Hypocalcemia occurs because the anticoagulant citrate dextrose binds with calcium. Sluggish bowel sounds and elevated blood pressure are not manifestations of electrolyte imbalances.
The nurse is assessing a patient with myasthenia gravis. Which are characteristics of this disease? Select all that apply. 1. Routine exercise provides an improvement in muscle strength. 2. Visual problems may be an early symptom. 3. There may be difficulty swallowing. 4. Great improvement occurs in muscle strength with physical therapy. 5. There may be poor articulation in speaking.
Correct Answer: 2, 3, 5 Rationale: The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are affected and the patient experiences either diplopia (unilateral or bilateral double vision) or ptosis (drooping of the eyelid). Patients may have periods of dysphagia (difficulty swallowing) and dysarthria (problems with speech). Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles, while rest will improve function. The voice is weak with a muffled nasal quality.
During an assessment the nurse becomes concerned that a patient is demonstrating early manifestations of amyotrophic lateral sclerosis. What findings did the nurse use to make this clinical determination? Select all that apply. 1. foot drop 2. slurred speech 3. weak hip flexor muscles 4. bilateral weak hand grasps 5. fine muscle fasciculations of the hands
Correct Answer: 2, 4, 5 Rationale: Muscle twitches or weakness in an extremity and slurred speech are common early manifestations. Fasciculations of involved muscles are common in the early stage of the disorder. With the loss of muscle innervation, the muscles atrophy, and paralysis results. Muscle mass decreases, and patients complain of progressive fatigue. Typically, the disease first affects the hands. Foot drop and weak hip flexor muscles may or may not be a manifestation of amyotrophic lateral sclerosis.
The nurse is reviewing the medical record of a patient with Alzheimer disease. Which stage should the nurse realize this patient is experiencing? 1. stage 1 2. stage 3 3. stage 4 4. stage 5
Correct Answer: 4 Rationale: Patients in stage 1 have memory problems that are neither experienced nor evident to others. In stage 3 family and friends begin to notice problems and the deficits may be measured or detected during a medical examination. Common problems include trouble finding words or names, decreased ability to remember names when introduced to new people, retaining little information when reading a passage, decreased ability to plan or organize, losing or misplacing valuable objects, and having performance issues in social and work settings that are noticeable to others. For stage 4, a careful medical interview will identify deficiencies in knowledge of recent events, impaired ability to perform challenging mental arithmetic, decreased capacity to perform complex tasks, and a reduced memory for personal history. The person often appears subdued and withdrawn, especially in social or mentally challenging situations. In stage 5, major deficits in memory and a decline in cognitive function emerge. Some assistance with ADLs becomes essential, but the person can usually eat and use the toilet. People with AD in this stage do usually retain knowledge about themselves, and know their name and the names of family members. Problems include inability to recall current address or telephone number; confusion about where they are as well as the date, day of the week, or season; and trouble with less challenging mental arithmetic.
A patient is being admitted for treatment of trigeminal neuralgia. Place an X on the body part on which the nurse should focus the assessment for this health problem.
Rationale: Trigeminal neuralgia is a disease of the trigeminal cranial nerve (V), which has three divisions: ophthalmic, maxillary, and mandibular. Trigeminal neuralgia is characterized by unilateral excruciating facial pain.
