NUR 237 Ch 23 and 24

During a seizure, it is important for the nurse to observe:

Where movement occurs and how it progresses

The nurse is assessing a patient on intravenous (IV) phenytoin (Dilantin). Which assessment finding is most concerning to the nurse?

c. Irregular apical pulse IV phenytoin can cause cardiac arrhythmias and hypotension, especially if given faster than 50 mg/min.

Interventions for the patient with moderate Parkinson's disease might include:

-allowing extra time to perform tasks -allowing rest periods during meals -ambulating at least twice a day

Your patient describes that she experiences visual disturbances as shimmering arc shaped lights in her field of vision and blocks in her vision similar to a blind spot. This is followed by a one-sided headache. She is experiencing:

-an aura-type disturbance prior to onset of a migraine headache. -Visual disturbances called a scotoma.

Treatment for myasthenia gravis may consist of:

-anticholinesterase therapy -IVIG therapy -Plasmapheresis

During a grand mal seizure, you could expect the patient to experience:

-loss of muscle tone -tonic-clonic movements -possible urinary incontinence

The teaching plan for the patient with epilepsy should include:

-refrain from drinking alcohol -wear a medic-alert bracelet or necklace -don't become overly tired -swim only with a partner

Huntington's disease is genetically transmitted and usually causes death within ---------- years after signs appear.

15 - 20

The test for the diagnosis of myasthenia gravis in which muscle strength is increased within 1 minute of the injection is the __________ test.

Tensilon An injection of Tensilon will increase muscle strength within 1 minute of injection and is a positive test for the diagnosis of myasthenia gravis.

A post CVA patient is experiencing motor difficulties on the right side of the body. You know that:

The accident occured on the left side of the brain.

One of the best things for building the self-esteem of the neurologically impaired person is:

To establish small, accomplishable goals

The nurse is educating the family of a patient in the late stages of amyotrophic lateral sclerosis (ALS). Which information is most important for the nurse to include?

Cognitive and mental capacities will most likely remain intact throughout the disease progression. Whereas the ability to move the upper limbs will likely be affected by the disease, it is important for families to remember that the patient's cognitive and mental capacity stays intact as the motor activity rapidly declines. Breathing and swallowing are often significantly affected by ALS.

While assessing patients for Parkinson's disease, which risks should be taken into consideration?

Family History

The nurse is caring for an anxious 20-year-old college student who just suffered his first seizure in his dorm room. The patient asks the nurse if he is now an epileptic. What is the nurse's best response?

a. "No. All other causes of seizure activity must be ruled out before the diagnosis of epilepsy is made." Epilepsy diagnosis is made after all other causes of seizure activity have proven negative. All seizures are not considered to be epilepsy.

The nurse is explaining Parkinson disease to the student nurse. Which statement indicates that the student nurse correctly understands the pathophysiology of the disease?

a. "Regardless of the actual etiology, Parkinson disease is caused by depletion of dopamine and excess of acetylcholine." The specific cause of Parkinson disease is unknown, but the basic pathophysiology is depletion of dopamine and excess of acetylcholine.

The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). Family members ask the nurse why their father had a seizure. Which response is best for the nurse to make?

a. "The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." Thrombi from a CVA can occlude vessels, cutting off oxygen supply to cells of the brain and causing a seizure.

The nurse is providing teaching to a patient newly diagnosed with simple partial seizure disorder. Which statement by the nurse is most accurate?

a. "Your seizures will typically only affect one side of your body." Simple partial seizures only involve one side of the brain and one side of the body. Complex partial seizures may or may not result in an alteration in level of consciousness. Generalized seizures affect both sides of the body. Simple partial seizures may respond to treatment.

The nurse is caring for a patient with brain tumor-related hydrocephalus who is scheduled to undergo placement of a ventriculoperitoneal (V-P) shunt. Which information is most important for the nurse to include when explaining the purpose of the procedure?

a. A V-P shunt redirects the cerebrospinal fluid (CSF) from the ventricles to the peritoneum. Obstruction of CSF flow may require placing a shunt to reduce CSF pressure and prevent increased intracranial pressure (ICP). A shunt is a tube placed in a ventricle and attached to a small manual pump that moves excess CSF fluid from the ventricles to the peritoneal cavity or into the atrium of the heart, so that it may be absorbed.

The nurse is caring for a patient with Guillain-Barré syndrome (GBS). Which area(s) should the care plan address? (Select all that apply.)

a. Assessment of advancing paralysis b. Provision for ventilation support c. Maintenance of adequate nutrition d. Prevention of complications of immobility ANS: A, B, C, D The nurse should include assessment of paralysis, provision for ventilation support, nutritional maintenance, and prevention of complications from immobility. The care plan should address assessment of hypotension rather than hypertension.

The nurse is completing a care plan for a stroke patient who is at risk for impaired physical mobility. Which interventions should the nurse include in the care plan? (Select all that apply.)

a. Assist the patient to stand. c. Ensure that the call light is within reach. d. Coach the patient in active range-of-motion (ROM). e. Reinforce the use of a walker or cane. ANS: A, C, D, E Fall precautions important for this patient include helping the patient to stand, placing the call light within reach, coaching the patient in active ROM, and reinforcing the use of a walker or cane. Reminding the patient to ambulate as much as possible would potentially increase the risk of falls.

The nurse is caring for a patient admitted with a transient ischemic attack (TIA). A carotid ultrasound reveals a 40% obstruction. The nurse anticipates that the treatment will likely consist of which factor(s)? (Select all that apply.)

a. Diet modification b. Lifestyle alteration c. Aspirin for antiplatelet aggregation ANS: A, B, C Since the patient has a carotid obstruction below 60%, the patient will likely be treated conservatively with measures that include diet and lifestyle modification in conjunction with aspirin therapy. Nitrates and endarterectomy are not initial treatment options for carotid obstruction below 60%.

The nurse is caring for an adult patient with a history of seizures. In the event of a seizure, the nurse should document which information? (Select all that apply.)

a. Duration of seizure b. Location of initiation of seizure c. Description of movements e. Presence of incontinence ANS: A, B, C, E The nurse should document seizure duration, location of seizure initiation, description of unilateral or bilateral movement, and presence of incontinence. The family's reaction to the seizure is not included in documentation of a seizure.

The nurse is preparing a care plan for a person with late-stage Parkinson disease. The nurse should plan interventions to address which problem(s)? (Select all that apply.)

a. Dysphagia c. Immobility d. Insomnia e. Urinary incontinence ANS: A, C, D, E The nurse should plan interventions to address dysphagia, immobility, insomnia, and urinary incontinence. Hallucinations are not part of the late Parkinson disease symptoms.

Which factor(s) is/are most likely a potential cause(s) of multiple sclerosis (MS)?

a. Environmental factors and genetic predisposition The cause of MS is not known, but it is attributed to an environmental factor (bacteria, virus, or chemical) combining with a genetic predisposition for the disease. Current thought also includes the hypothesis that MS is an autoimmune disease where the immune system attacks healthy central nervous system tissues.

The nurse is caring for a patient with Huntington chorea. Which symptom(s) is/are characteristic manifestation(s) of this disease? (Select all that apply.)

a. Fidgeting b. Restlessness c. Constant movement d. Dementia ANS: A, B, C, D Huntington chorea is a degenerative neurologic disorder characterized by abnormal movements (chorea). The disease begins with the patient being fidgety and progresses to constant movement and intellectual decline. Death usually occurs within 15 to 20 years after diagnosis.

Which drug therapy is indicated for an acute severe attack of multiple sclerosis (MS)?

a. Intravenous (IV) methylprednisolone IV methylprednisolone is the standard treatment for the severe acute attack of MS. Interferon is used to prevent attacks.

The nurse is aware that absence (petit mal) seizures are difficult to detect for which reason(s)? (Select all that apply.)

a. Lack of an aura b. Appearance as a brief moment of absentmindedness d. Absence of patient memory of the event e. Absence of postictal signs ANS: A, B, D, E Factors that make petit mal seizures difficult to detect include lack of an aura and appearance as a brief moment of absentmindedness with no patient memory of the event or presence of postictal signs. Petit mal seizures do not result in LOC.

The nurse is caring for a patient with bacterial meningitis. What interventions should the nurse include in the plan of care?

a. Maintain a quiet environment with minimal stimulation. The environment is kept quiet with minimal stimulation to reduce the possibility of seizure. The care is done with general precautions. Fluid intake is encouraged, as are daytime naps to preserve energy.

The nurse outlines nutritional needs for the patient with multiple sclerosis (MS). Which dietary instruction(s) is/are most important for the nurse to emphasize? (Select all that apply.)

a. Maintain fluid intake of at 1500 mL each day. b. Include intake of high-fiber foods in the diet. d. Add supplemental calcium and vitamin D to the diet. ANS: A, B, D Fluids and high fiber in the diet will prevent constipation, and calcium and vitamin D will help in preventing osteoporosis. High levels of carbohydrates and fats are not emphasized in the diet for an MS patient.

Which nursing intervention best encourages self-feeding in a patient with right-sided paralysis after a CVA?

a. Place finger foods on the left side of the plate. Finger foods on the nonparalyzed side encourage self-feeding. Privacy is more supportive to early efforts than being in a common dining room. Smaller helpings on the same side of the nonparalyzed limb are conducive to self-feeding.

To help prevent aspiration while feeding a patient who has a right-sided paralysis, the nurse should implement which intervention(s)? (Select all that apply.)

a. Place the patient in high Fowler position. b. Instruct the patient to tilt the head and neck forward. d. Place food in the left side of the mouth. e. Avoid mixing foods with different textures. ANS: A, B, D, E To help prevent aspiration in this patient, the nurse should position the patient in high Fowler position, instruct the patient to tilt the head and neck forward, place food in the left side of the mouth, and avoid mixing foods with different textures. Drinking through a straw rather than sipping from a cup increases the risk for aspiration.

The caregiver of a patient with Parkinson disease is concerned with the patient's recent weight loss. The home health nurse should suggest which modification to help the caregiver enhance the patient's nutrition?

a. Provide six mini-meals throughout the day. Mini-meals can be eaten before food cools since it takes longer for the patient with Parkinson disease to eat. Large meals are overwhelming and may become unappetizing before they can be consumed. Reduced fluid and increased dairy products increase the threat of constipation.

The nurse is assessing a patient with suspected myasthenia gravis. The nurse is aware that which assessment finding supports this diagnosis?

a. Ptosis Symptoms of myasthenia gravis include diplopia (double vision), difficulty chewing and swallowing, and ptosis.

The nurse is educating a patient about his cluster headaches. The nurse includes information that cluster headaches may be accompanied by which signs or symptoms? (Select all that apply.)

a. Reddened conjunctiva b. Nasal congestion c. Ptosis e. Sensitivity to touch ANS: A, B, C, E Manifestations of cluster headaches may include severe unilateral orbital, supraorbital, or temporal pain along with one of the following: redness of the conjunctiva of the eye, tearing, nasal congestion, dripping nose, facial swelling, pupil constriction, ptosis (drooping) of the eyelid, and sensitivity to touch. Cluster headaches might cause restlessness (patients often pace), not lethargy.

The patient with a right-sided paralysis from a stroke becomes frustrated when attempting to self-feed. He throws the spoon at the nurse and begins to cry. What nursing action(s) is/are most appropriate at this time? (Select all that apply.)

a. Retrieve the spoon and sit quietly for a few seconds. b. Touch the patient and inquire if he would rather have a high-protein milkshake for his meal. c. Remind the patient that such behavior is not acceptable. d. Add an intervention to the NCP for increased support with self-feeding. ANS: A, B, C, D Quietly retrieving the spoon, offering an alternative, reassuring the patient, and devoting new interventions related to the self-feeding deficit are appropriate nursing actions in this situation. Completing an incident report is not necessary unless the nurse or someone else was injured.

The nurse is planning care for a patient with Parkinson disease. Which problem statement/nursing diagnosis is most appropriate for the patient experiencing bradykinesia?

a. Risk for falls Bradykinesia is a condition that is associated with Parkinson disease, characterized by slow speech and movement, which produces poor body balance, a characteristic shuffling gait, and difficulty initiating movement. This condition places the patient at risk for falling.

Which problem statement/nursing diagnosis is most appropriate for a person with Parkinson disease?

a. Risk for falls related to unsteady gait. Rigidity and impaired balance with the propulsive gait create a risk for falls. The tremor decreases with voluntary movement, making eating relatively trouble free. Drooling is not a threat for aspiration, and there is no characteristic nausea.

The nurse is assisting a patient with agnosia after a CVA. Which intervention is most appropriate?

a. Showing the patient a spoon while calling it by name and describing its purpose. Identifying objects and their intended use is helpful to people with agnosia who can no longer recognize items. The other options are helpful to people with apraxia, hemianopsia, and altered coordination, respectively.

The student nurse is researching relapsing-progressive forms of multiple sclerosis (MS). What characteristic(s) is/are typical of this form of the disease? (Select all that apply.)

a. Steadily worsens c. Clear, acute relapses ANS: A, C Steady worsening and clear acute relapses are the principle characteristics of relapsing-progressive MS.

Which condition(s) may cause seizures? (Select all that apply.)

a. Stroke b. Cerebral tumor c. Hyperpyrexia d. Epilepsy e. Metabolic toxicity ANS: A, B, C, D, E Stroke, cerebral tumors, hyperpyrexia, epilepsy, and metabolic toxicity are conditions that may all potentially cause seizures.

The home health nurse is planning an exercise program for a patient with multiple sclerosis (MS). Which exercise would be most beneficial for this patient?

a. Swimming An exercise program is very beneficial for the MS patient to relieve spasticity and improve coordination (Harmon, 2011). Because of fatigue, it is often difficult to convince MS patients to exercise. Swimming provides considerable benefits as exercising in water is less fatiguing than exercising out of water.

The home health nurse assesses the patient with Parkinson disease who just started taking carbidopa-levodopa. The nurse should be alert for which side effect(s)? (Select all that apply.)

a. Urinary retention c. Diaphoresis d. Orthostatic hypotension ANS: A, C, D Carbidopa-levodopa may cause urinary retention, diaphoresis, and orthostatic hypotension. The medication should not cause itching, and it may turn the urine dark.

A patient diagnosed with a primary brain tumor asks the nurse if this is a common disease. Which response is most appropriate for the nurse to make?

b. "About 40,000 people a year are diagnosed with a primary brain tumor." About 200,000 new brain tumors are discovered each year in the United States with approximately 40,000 of those being primary tumors and the rest are metastatic tumors from a different site of origin. Many primary brain tumors are benign. Telling the patient his question doesn't really matter is dismissive and nontherapeutic.

The dysarthric patient seated in the dining room of the long-term care facility yells, "Poon! Poon! Poon!" with increasing frustration. What is the nurse's best response?

b. "Are you asking for a spoon?" Attempting to interpret the dysarthric communication through questions that can be answered simply will reduce frustration.

The nurse is providing medication teaching to a patient with epilepsy who is taking phenytoin (Dilantin). Which statement best indicates that the nurse's teaching has been successful?

b. "I should visit the dentist every 3 to 6 months while taking this medication." Dilantin can cause gingival hyperplasia. The patient should brush teeth and floss regularly, and schedule dentist visits every 3 to 6 months. Alcohol interferes with the metabolism of anticonvulsants, increases lethargy, and may trigger seizures. The patient should not consume alcohol at all while taking Dilantin. The patient should not take antacids within 2 hours of taking Dilantin. Dilantin may turn the urine pink.

A patient was recently diagnosed as having Bell palsy. Which nursing intervention is most important for the nurse to include in the patient's care plan?

b. Administer artificial tears and aclyclovir. Treatment consists of closing and patching the eye if it loses the blink reflex. Artificial tear eyedrops also are used to prevent dryness of the cornea. Corticosteroids are given if they can be started right after the beginning of symptoms. They are ineffective if delayed more than 7 days. Acyclovir may be prescribed as well, since herpes virus may be a causative organism. Bell palsy is usually a painless condition. Bell palsy does not pose a particular risk for aspirations. Cool air may trigger or exacerbate Bell palsy.

Which symptom is a key sign of a brain tumor?

c. A headache that awakens patient A headache that awakens the patient is an early sign of a brain tumor. Morning nausea, difficulty reading, and increasing blood pressure are nonspecific findings that can be attributed to multifactorial causes.

The nurse is caring for a patient with myasthenia gravis. The patient asks the nurse if she can return to her normal job as a data entry specialist. Which symptom would most affect the patient's ability to perform her job?

b. Diplopia A data entry specialist spends large amounts of time entering data in the computer. Ptosis, dysphagia, and aphasia are all symptoms associated with myasthenia gravis, but diplopia, or double vision, will cause the patient the most difficulty with using a computer.

The nurse instructs a person taking phenytoin (Dilantin) that periodic blood tests will be necessary. The nurse explains that the laboratory checks will monitor for which potential medication-induced change?

b. Liver damage Periodic blood tests are recommended for people taking phenytoin to monitor for liver damage.

To enhance more erect posture in the patient with Parkinson disease, the nurse should encourage the patient to practice which activity?

b. Sleep in the prone position. The nurse should teach the patient to consciously assume correct posture. Sleeping in the prone position without a pillow will help to improve erect posture. Imagining stepping over something helps prevent "freezing" when walking. Walking may also improve by having the patient think about imaginary lines across the pathway on which to walk. The patient should be encouraged to exercise; the physical therapist will institute an exercise program to help the patient maintain muscle function and promote joint mobility.

The nurse is assessing a patient with Parkinson disease. Which statement likely characterizes this patient's tremors?

b. Tremors decrease with voluntary movement. Tremors in Parkinson disease decrease with voluntary movement, are absent during sleep, and occur when the body is at rest. Parkinsonian muscle activity is that of "pill rolling." Tonic/clonic movement is associated with seizures.

Hydrocephalus is a complication after an intercerebral bleed because:

blood in the cerebral ventricular system interferes with the resorption of CSF.

Besides small emboli or small blood vessel rupture, a TIA may be caused by

blood vessel constriction

Signs and symptoms of Guillain-Barré syndrome (GBS) usually appear within how many days after a viral infection?

c. 10 to 21 days The cause of GBS is not known, but it usually follows a viral respiratory infection or gastroenteritis in adults within 10 to 21 days.

The nurse is writing the care plan for a cerebrovascular accident (CVA) patient who has partial left-sided paralysis and is experiencing ataxia. Which intervention is most beneficial for this patient?

c. Place the patient's call light on the right side of the patient and remind her to call for assistance before getting up. The patient with ataxia has experienced a loss of balance or poor coordination; therefore, placing the call light on this patient's right side and reminding her to call for help will best address her high risk for falling. Pureed foods and thickened liquids are necessary for the patient with dysphagia, and a communication board would assist a patient with dysarthria or aphasia.

Which type of multiple sclerosis (MS) is the most common?

c. Relapsing-remitting Relapsing-remitting is the most common type of MS.

The home health nurse is caring for a patient with multiple sclerosis (MS) who complains of severe fatigue. What activity should the nurse suggest to diminish the effects of fatigue?

c. Scheduling rest periods during the day Scheduling and observing rest periods during the day will reduce fatigue. Heat increases sense of fatigue. Muscular problems are associated with ineffective impulse transmission rather than muscle weakness related to nutritional deficiency.

The patient reports intense intermittent headaches over the last 6 months that are preceded by specific symptoms. What symptom is the patient most likely experiencing?

c. Scotoma The headaches are most likely migraines. Scotoma (spots before the eyes) is the typical prodromal symptom of a migraine headache.

The home care nurse is visiting a patient in the late stages of amyotrophic lateral sclerosis (ALS). Which example indicates that the patient accepts the grief associated with the condition and prognosis?

c. The patient talks with his family about his desires for his funeral. Planning with family signals acceptance. Crying, joking, and sleeping are efforts at denial.

Two viruses that are especially associated with the etiology of Guillain-Barré syndrome (GBS) are ___________ and ___________.

cytomegalovirus; Epstein-Barr virus Epstein-Barr virus; cytomegalovirus Cytomegalovirus and Epstein-Barr virus are especially associated with the development of GBS.

The nurse is caring for a patient with Huntington disease. The patient asks if his disease will affect future children. Which reply is most appropriate?

d. "The genetic nature of the disease means that 50% of your children will inherit it." ANS: D Huntington disease is an autosomal dominant disorder, meaning that 50% of the children of a person who has the disease will inherit it. If a child does not inherit the disease, the gene is not passed on to the next generation. Huntington disease has an autosomal link and can be passed on to 50% of the children of a person with the disease.

The nurse reinforces the information given by the physician that endarterectomy as an intervention for stroke prevention is reserved for people who have carotid obstruction of greater than what percentage?

d. 60% ANS: D Endarterectomy is reserved for people with carotid obstruction of more than 60%.

The nurse is caring for a stroke patient who is experiencing homonymous hemianopsia. The patient asks if he is going to have any limitations when discharged from the hospital. The nurse anticipates the patient will be restricted from what activity?

d. Driving a vehicle ANS: D Homonymous hemianopsia is blindness in part of the visual field of both eyes. Driving a vehicle may be very dangerous for this patient. With proper occupational therapy, the patient should be able to ambulate independently, cook, and read.

Following a craniotomy for the removal of a brain tumor, the patient exhibits nuchal rigidity, rash on the chest, headache, and a positive Brudzinski sign. What do these assessment findings indicate to the nurse?

d. Meningitis ANS: D Nuchal rigidity, skin rash, headache, and a positive Brudzinski sign are indicative of meningitis.

Which factors predominantly determine probable diagnosis of multiple sclerosis (MS)?

d. Signs and symptoms assessed and reported by the patient No laboratory test will definitively establish a diagnosis of MS, although most patients have elevated IgG levels in their cerebrospinal fluid (CSF), with the presence of oligoclonal bands (bands of IgG produced by electrophoresis of the CSF). An magnetic resonance imaging (MRI) study usually shows characteristic white matter lesions scattered through the spinal cord and/or brain, which confirms the diagnosis of MS. However, the clinical signs and symptoms presented by a patient usually are sufficient characteristics of the disorder to allow the neurologist to make a diagnosis that the patient possibly or probably has MS.

A nursing intervention for safety of the patient with Guillain Barre syndrome is to:

keep the head of the patient's ed elevated 15 - 30 degrees at all times

An effective treatment to stop a migraine headache for many people is to:

lie down in an odor free, darkened room with the eyes closed

Assessment findings of weakness of a leg, blurred vision, spasticity of muscles, and a positive Lhermitte's sign for a patient will most likely lead to a diagnosis of:

myasthenia gravis

Patients taking levodopa to control Parkinson's disease should be assessed for the side effect of:

orthostatic hypotension

An expected outcome for the patient with Parkinson's disease who has a nursing problem of potential for injury would be:

patient will not experience a fall while ambulating before discharge

The triad of Parkinson disease is __________, __________, and __________.

tremor; bradykinesia; rigidity Tremor, bradykinesia, and rigidity are included in the triad of Parkinson disease.

When assessing a patient with amyotrophic lateral sclerosis, the nurse would find:

weakness of voluntary muscles

When planning nursing care for a patient with multiple sclerosis, remember that the patient:

will experience more fatigue in a hot environment