NUR 257 PrepU 64 Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies
A patient undergoing rehabilitation reports problems with constipation. Which suggestion would be least appropriate?
"Keep your fluid intake to fewer than 2 liters per day." Explanation: To promote bowel elimination, the nurse should suggest a daily fluid intake of 2 to 3 liters per day unless contraindicated and encourage the patient to respond to the urge to defecate. Increasing the intake of fruits and vegetables and encouraging an increase in physical activity are appropriate to stimulate peristalsis.
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary." Explanation: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.
The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)
-Set a daily defecation time that is within 15 minutes of the same time every day. -Have an adequate intake of fiber containing foods. -Have a fluid intake between 2 and 4 L/day.
What diet can the nurse recommend to a patient with hypoproteinemia that spares protein?
A diet high in carbohydrates Explanation: Wounds from which body fluids and protein drain place the patient in a catabolic state and predispose to hypoproteinemia and serious secondary infections. Protein deficiency must be corrected to promote the healing of the pressure ulcer. Carbohydrates are necessary to "spare" the protein and to provide an energy source.
A client has a neurological defect and will be transferred to a nursing home because family members are unable to care for the client at home. While receiving a bed bath, the client yells at the nurse, "You don't know what you are doing!" What is the best reaction by the nurse?
Accept the patient's behavior and do not take it personally.
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
Administer atropine to control the side effects of edrophonium.
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?
Alternatively patch one eye every 2 hours.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?
Antibodies are removed from the plasma. Explanation: Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client.
A female client has been achieving significant improvements in her ADLs since beginning rehabilitation after a brain hemorrhage. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?
Appraising the family's involvement in the client's ADLs.
The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?
Appropriate assistive devices Explanation: Clients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A health care aide is not needed by most clients.
Which nursing intervention is the priority for a client in myasthenic crisis?
Assessing respiratory effort
Which drug should be available to counteract the effect of edrophonium chloride?
Atropine
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
Avoid hot temperatures. Explanation: Fatigue affects most people with MS. Avoidance of hot temperatures may help control fatigue. A balance of rest and activity is a good strategy, but avoidance of any physical activity is not recommended. Avoidance of all alcohol is a good strategy. Analgesics may be required for pain management.
A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.
Bathing Toileting Eating
A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?
Cooking
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
Diplopia and ptosis
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?
Edrophonium (Tensilon) Explanation: The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.
Which is the most common cause of acute encephalitis in the United States?
Herpes simplex virus
A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. The nurse planning the client's care. Who will the client's condition affect?
Him and his entire family Explanation: Clients and families who suddenly experience a physically disabling event or the onset of a chronic illness are the ones who face several psychosocial adjustments, even if the client recovers completely.
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
Which is the primary vector of arthropod-borne viral encephalitis in North America?
Mosquitoes Explanation: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord?
Multiple sclerosis
The most common cause of cholinergic crisis includes which of the following?
Overmedication
A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation?
Priority setting is helpful in dealing with the impact of the disability.
A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?
Repositioning the patient about once a shift
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
Stage II pressure ulcer Explanation: -A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. -A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. -A stage III pressure ulcer extends into the subcutaneous tissue. -A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news?
The client will experience grief in an individualized manner.
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:
complications. Explanation: Measures such as position changes and prevention of skin breakdown and contractures are essential aspects of care during the early phase of rehabilitation. The nursing goal is to prevent complications that may interfere with the client's potential to recover function.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:
rest in an air-conditioned room.
The nurse is providing care for a client who has limited mobility after a stroke. In order to assess the client for contractures, the nurse should assess the client's:
ROM
An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?
Isometric Explanation: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the client. Passive exercises are carried out by the therapist or the nurse without assistance from the client. Resistive exercises are carried out by the client working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?
Controlling seizures and increased intracranial pressure Explanation: There is no specific medication for arboviral encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.
A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?
Functional Independence Measure Explanation: One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (trade marked- FIM), a minimum data set consisting of 18 items. -The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.
A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:
turn him frequently. Explanation: The most important intervention for maintaining skin integrity is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and pressure ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and foot drop by maintaining the foot in a dorsiflexed position
