Test 3 Neurological Dysfunction #3 - From Mom
The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? A. Vision changes B. Absent deep tendon reflexes C. Tremors at rest D. Flaccid muscles
Correct Answer: A. Vision changes Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of multiple sclerosis. Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS) characterized by inflammation, demyelination, gliosis, and neuronal loss. Neurological symptoms vary and can include vision impairment, numbness and tingling, focal weakness, bladder and bowel incontinence, and cognitive dysfunction. Symptoms vary depending on lesion location. Option B: Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's sign may be positive. The diagnosis of RR MS is made with at least two CNS inflammatory events. Although different diagnostic criteria have been used for MS, the general principle of diagnosing the RR course has involved establishing episodes separated in "time and space." Option C: Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in clients with multiple sclerosis. Symptoms from relapses frequently resolve, however over time, residual symptoms relating to episodes of exacerbation accrue. This accrual of symptoms, generally after 10 to 15 years, results in long-term disability over time. Neurologic manifestations are heterogeneous in severity and degree of recovery. Option D: Affected muscles are spastic, rather than flaccid. Clinical symptoms characterized by acute relapses typically first develop in young adults. A gradually progressive course then ensues with permanent disability in 10 to 15 years. Relapses often recover either partially or completely over weeks and months, frequently without treatment. Over time, residual symptoms from relapses without complete recovery accumulate and contribute to general disability.
Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, "He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he's comatose. We intubated him and he's maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag." Which intervention by the nurse has the highest priority? A. Assessing the left leg. B. Assessing the pupils. C. Placing the client in Trendelenburg's position. D. Assessing level of consciousness.
Correct Answer: A. Assessing the left leg. In the scenario, airway and breathing are established so the nurse's next priority should be circulation. With a compound fracture of the femur, there is a high risk of profuse bleeding; therefore, the nurse should assess the site. Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Inadequate circulating volume compromises systemic tissue perfusion. Option B: Test sensation of peroneal nerve by pinch or pinprick in the dorsal web between the first and second toe, and assess the ability to dorsiflex toes if indicated. Length and position of peroneal nerve increase risk of its injury in the presence of leg fracture, edema or compartment syndrome, or malposition of traction apparatus. Option C: The nurse doesn't have enough data to warrant putting the client in Trendelenburg's position. Handle injured tissues and bones gently, especially during the first several days. This may prevent the development of fat emboli (usually seen in the first 12-72 hr), which are closely associated with fractures, especially of the long bones and pelvis. Option D: Neurologic assessment is a secondary concern to airway, breathing, and circulation. Perform neurovascular assessments, noting changes in motor and sensory function. Ask the patient to localize pain and discomfort. Impaired feeling, numbness, tingling, increased or diffuse pain occurs when circulation to nerves is inadequate or nerves are damaged.
To encourage adequate nutritional intake for a female client with Alzheimer's disease, the nurse should: A. Stay with the client and encourage him to eat. B. Help the client fill out his menu. C. Give the client privacy during meals. D. Fill out the menu for the client.
Correct Answer: A. Stay with the client and encourage him to eat. Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Offer sweet and salt substitutes. Helps satisfy desire for these tastes as taste buds decrease with aging without compromising diet. Allow for interaction during mealtime to promote interest in eating. Option B: During the middle stages of Alzheimer's, distractions, too many choices, and changes in perception, taste, and smell can make eating more difficult. Be flexible with food preferences. It is possible the person may suddenly develop certain food preferences or reject foods he or she may have liked in the past. Option C: Eat together. Give the person the opportunity to eat with others. Keeping mealtimes social can encourage the person to eat. Limit distractions. Serve meals in quiet surroundings, away from the television and other distractions. Option D: Offer one food item at a time. The person may be unable to decide among the foods on his or her plate. Serve only one or two items at a time. For example, serve mashed potatoes followed by the main entree.
The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction? A. Tachycardia B. Increased salivation C. Hypotension D. Apnea
Correct Answer: A. Tachycardia Systemic absorption of atropine sulfate can cause tachycardia, palpitations, flushing, dry skin, ataxia, and confusion. To minimize systemic absorption, the client should apply digital pressure over the punctum at the inner canthus for 2 to 3 minutes after instilling the drops. Tachycardia is the most common side effect; titrate dose to effect when treating bradyarrhythmia in patients with coronary artery disease. Atropine may precipitate acute angle glaucoma, pyloric obstruction, urinary retention due to benign prostatic hyperplasia, or viscid plugs in patients with chronic lung diseases. Option B: The drug also may cause dry mouth. The most common adverse effects are related to the drug's antimuscarinic properties, including xerostomia, blurred vision, photophobia, tachycardia, flushing, and hot skin. Constipation, difficulty with urination, and anhidrosis can occur, especially in at-risk populations (most notably, the elderly). Option C: Atropine is an antimuscarinic that works through competitive inhibition of postganglionic acetylcholine receptors and direct vagolytic action, which leads to parasympathetic inhibition of the acetylcholine receptors in smooth muscle. The end effect of increased parasympathetic inhibition allows for preexisting sympathetic stimulation to predominate, creating increased cardiac output and other associated antimuscarinic side effects as described herein. Option D: It isn't known to cause apnea. Overdose can lead to increased antimuscarinic side effects presenting with dilated pupils, warm, dry skin, tachycardia, tremor, ataxia, delirium, and coma. In extreme toxicity, circulatory collapse secondary to respiratory failure may occur after paralysis and coma. Ten milligrams or less may be fatal to a child, while there is no known adult lethal dose.
A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière's disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss. B. Vertigo, vomiting, and nystagmus. C. Vertigo, pain, and hearing impairment. D. Vertigo, blurred vision, and fever.
Correct Answer: A. Vertigo, tinnitus, and hearing loss. Ménière's disease, an inner ear disease, is characterized by the symptom triad of vertigo, tinnitus, and hearing loss. The combination of vertigo, vomiting, and nystagmus suggests labyrinthitis. Ménière's disease rarely causes pain, blurred vision, or fever. Meniere disease is a disorder of the inner ear characterized by hearing loss, tinnitus, and vertigo. In most cases, it is slowly progressive and has a significant impact on the social functioning of the individual affected. Option B: Patients with a definite Meniere disease according to the Barany Society have two or more spontaneous episodes of vertigo with each lasting 20 minutes to 12 hours; audiometrically documented low- to medium- frequency sensorineural hearing loss in one ear, defining and locating to the affected ear on in at least one instance prior, during or after one of the episodes of vertigo; fluctuating aural symptoms (fullness, hearing, tinnitus) located in the affected ear; and not better accounted for by any other vestibular diagnosis. Option C: Probable Meniere disease can include the following clinical findings: two or more episodes of dizziness or vertigo, each lasting 20 minutes to 24 hours; fluctuating aural symptoms (fullness, hearing, or tinnitus) in the affected ear; and the condition is better explained by another vestibular diagnosis. Option D: At the emergency room or in the general practice the physician will differentiate between vertigo of central, peripheral, and cardiovascular cause. Red flags for a central origin of vertigo, according to Harcourt et al., are neurological symptoms or signs, acute deafness, new type or onset of headache, or vertical/torsional/rotatory nystagmus.
A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client? A. A private room down the hall from the nurses' station. B. An isolation room three doors from the nurses' station. C. A semi-private room with a 32-year-old client who has viral meningitis. D. A two-bedroom with a client who previously had bacterial meningitis.
Correct Answer: B. An isolation room three doors from the nurses' station A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission. Patients suspected of having meningococcal meningitis should be placed in droplet precautions until they have received 24 hours of antibiotics. Close contacts should also be treated prophylactically. Ciprofloxacin, rifampin, or ceftriaxone may be used. Close contacts are defined as people within 3 feet of the patient for more than 8 hours during the seven days before and 24 hours after receiving antibiotics. People exposed to the patient's oral secretions during this time should also be treated. Option A: During the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. The mortality for bacterial meningitis varies from 10-15%. Survival depends on early recognition of acute bacterial meningitis, followed by administration of appropriate antibiotic therapy. Delay in treatment can result in increased intracranial pressure causing decreased cerebral perfusion and may rapidly lead to loss of consciousness and death. Option C: Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. These patients need inpatient treatment until all symptoms have disappeared, therefore the nursing staff will be responsible for administration as well as monitoring for therapeutic effectiveness and adverse drug events, reporting any concerns to the team. Option D: Immunity to Bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease. Vaccines are available to help prevent bacterial meningitis. Children can get a meningitis vaccine around ages 11 to 12, followed by a booster vaccine at age 16. Bacterial meningitis is more common in infants under 1 year of age and young people ages 16 to 21.
A male client is color blind. The nurse understands that this client has a problem with: A. Rods. B. Cones. C. Lens. D. Aqueous humor.
Correct Answer: B. Cones. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Very few individuals are truly color blind, but instead, see a disrupted range of colors. The most common forms are protanopia and deuteranopia, conditions arising from loss of function of one of the cones, leading to dichromic vision. Option A: Rods are sensitive to low levels of illumination but can't discriminate color. Rods are the cells primarily responsible for scotopic vision, or low-light vision. Rods are the more abundant cell-type of the retina and reach their maximum density approximately 15 to 20 degrees from the fovea, a small depression in the retina of the eye where visual acuity is highest. There are approximately 90 million rod cells in the human retina. Option C: The lens is responsible for focusing images. The lens is the adjustable component of the refractive system: its shape is altered by the contraction or relaxation of the ciliary muscle to focus on objects that are near or far. Option D: Aqueous humor is a clear watery fluid and isn't involved in color perception. Aqueous humor is a low viscosity fluid secreted from plasma components by the ciliary body into the posterior chamber of the eye. The humor then travels to the anterior chamber and proceeds to drain into the systemic cardiovascular circulation by an incompletely understood mechanism. Aqueous humor circulation forms the basis of intraocular pressure (IOP), which is associated with glaucoma; this is how the synthesis, circulation, and drainage of aqueous humor become clinically significant.
An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by: A. Increasing the exudative reaction of ocular tissue. B. Decreasing leukocyte infiltration at the site of ocular inflammation. C. Inhibiting the action of carbonic anhydrase. D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.
Correct Answer: B. Decreasing leukocyte infiltration at the site of ocular inflammation. Dexamethasone exerts its therapeutic effect by decreasing leukocyte infiltration at the site of ocular inflammation. This reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring. Dexamethasone is a widely prescribed drug by many healthcare professionals, including the nurse practitioner. However, it is essential to know that this potent steroid has many adverse effects, and patient monitoring is critical. Option A: Dexamethasone is a potent glucocorticoid with very little, if any, mineralocorticoid activity. Dexamethasone's effect on the body occurs in a variety of ways. It works by suppressing the migration of neutrophils and decreasing lymphocyte colony proliferation. The capillary membrane becomes less permeable, as well. Lysosomal membranes have increased stability. Option C: There are higher concentrations of vitamin A compounds in the serum, and prostaglandin, and some cytokines (interleukin-1, interleukin-12, interleukin-18, tumor necrosis factor, interferon-gamma, and granulocyte-macrophage colony-stimulating factor) become inhibited. Option D: Dexamethasone and other anti-inflammatory agents don't produce any type of miotic reaction. In the treatment of inflammation, it is advisable to start with low doses of 0.75 mg/day, which may titrate to 9 mg/day, with dosing divided into 2 to 4 doses throughout the day. This applies to intravenous, intramuscular, and oral administrations. Less may be used when directly administered to the lesion or tissue with dosing ranging from 0.2 to 6 mg per day.
Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed? A. In 30 to 45 seconds B. In 10 to 15 minutes C. In 30 to 45 minutes D. In 1 to 2 hours
Correct Answer: B. In 10 to 15 minutes When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn't exceed 100 mg in 24 hours. It is crucial to monitor respiratory and cardiovascular status, blood pressure, heart rate, and symptoms of anxiety in patients taking diazepam. Option A: The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can't be repeated in 30 to 45 seconds because the first dose wouldn't have been administered completely by that time. 0.15 to 0.20 mg/kg IV per dose, and may be repeated once if needed. Do not exceed 10 mg per single dose. Rectal administration of 0.2 to 0.5 mg/kg administered one time. Do not exceed 20 mg per dose. Option C: Waiting longer than 15 minutes to repeat the dose would increase the client's risk of complications associated with status epilepticus. When administered intravenously, diazepam actS within 1 to 3 minutes, while oral dosing onset ranges between 15 to 60 minutes. Diazepam is long-lasting with a duration of action of more than 12 hours. Option D: Diazepam is a fast-acting potent anxiolytic popular in use due to its broad therapeutic index, low toxicity, and improved safety profile. Nonetheless, diazepam is still a drug with high potential for use disorder associated with severe adverse/toxic effects.
A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis? A. Impaired physical mobility B. Ineffective breathing pattern C. Disturbed sensory perception (tactile) D. Self-care deficit: Dressing/grooming
Correct Answer: B. Ineffective breathing pattern Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway. Option A: Continually assess motor function (as spinal shock or edema resolves) by requesting the patient to perform certain actions such as shrug shoulders, spread fingers, squeeze, release examiner's hands. Evaluates status of individual situation (motor-sensory impairment may be mixed or not clear) for a specific level of injury, affecting type and choice of interventions. Option C: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks ("2 in above nipple line"). Provide tactile stimulation, touching the patient in intact sensory areas (shoulders, face, head). Option D: The other options may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but don't take precedence over a diagnosis of ineffective breathing pattern. Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance and ability. Prevents fatigue, allowing opportunity for maximal efforts and participation by patient
After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by: A. Instilling one drop of pilocarpine 0.25% into both eyes daily. B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. C. Instilling one drop of pilocarpine 0.25% into the right eye daily. D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.
Correct Answer: B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily. The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, OU signifies both eyes, and "q.i.d." means four times a day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily. Pilocarpine is a muscarinic acetylcholine agonist that is effective in the treatment and management of acute angle-closure glaucoma and radiation-induced xerostomia. Although not a first-line treatment for glaucoma, it is useful as an adjunct medication in the form of ophthalmic drops. Option A: Pilocarpine is approved for use as an agent to decrease IOP in cases of glaucoma, as well as in the management of xerostomia resulting from radiation exposure and Sjogren disease. Its mechanism of action includes both full and partial agonism of the muscarinic M3 receptor, which is an acetylcholine receptor. It is important to note that pilocarpine may have effects on the M1-M3 receptor subtypes, which causes parasympathetic side effects later discussed in this paper. The M3 receptor is an excitatory receptor expressed in gastric glands, salivary glands, and smooth muscle cells, such as those present in the pupillary sphincter and ciliary bodies. Option C: By stimulating the Gq receptor, the M3 receptor can activate phospholipase C. This leads to the creation of the second messenger's inositol trisphosphate and diacylglycerol, as well as calcium and protein kinase. M3 cholinergic agonists, therefore, result in the upregulation of calcium, and ultimately smooth muscle contraction such as in the pupillary sphincter muscle. Option D: When used as a miotic agent, pilocarpine is available in the form of ophthalmologic eye drops. This dose form will result in ciliary contraction (a contraction of the iris), which will increase aqueous humor outflow, miosis, and accommodation. The ciliary body connects to the zonular fibers that control the accommodation of the lens. Contraction of the ciliary body will relax the zonular fibers, which results in a more spherical shape of the lens and therefore allowing aqueous outflow to occur. This conformational change is helpful to decrease intraocular pressure in glaucoma.
A female client who's paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis? A. The client leaves the side rails down. B. The client uses a mirror to inspect the skin. C. The client repositions only after being reminded to do so. D. The client hangs the left arm over the side of the wheelchair.
Correct Answer: B. The client uses a mirror to inspect the skin. Using a mirror enables the client to inspect all areas of the skin for signs of breakdown without the help of staff or family members. Inspect skin daily. Observe for pressure areas, and provide meticulous skincare. Teach the patient to inspect skin surfaces and to use a mirror to look at hard-to-see-areas. Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation. This is a lifelong consideration. Option A: The client should keep the side rails up to help with repositioning and to prevent falls. Perform and assist with full ROM exercises on all extremities and joints, using slow, smooth movements. Hyperextend hips periodically. Enhances circulation, restores and maintains muscle tone and joint mobility, and prevents disuse contractures and muscle atrophy. Option C: The paralyzed client should take responsibility for repositioning or for reminding the staff to assist with it if needed. Reposition periodically even when sitting in a chair. Teach the patient how to use weight-shifting techniques. Reduces pressure areas, promotes peripheral circulation. Option D: A client with left-side paralysis may not realize that the left arm is hanging over the side of the wheelchair. However, the nurse should call this to the client's attention because the arm can get caught in the wheel spokes or develop impaired circulation from being in a dependent position for too long.
The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function
Correct Answer: C. Cerebral function The mental status examination assesses functions governed by the cerebrum. Some of these are orientation, attention span, judgment, and abstract reasoning. Cerebrum is the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision, and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement. Option A: Cerebellar function testing assesses coordination, equilibrium, and fine motor movement. Cerebellum is located under the cerebrum. Its function is to coordinate muscle movements, maintain posture, and balance. Option B: Intellectual functioning isn't the only cerebral activity. When assessing intelligence to make decisions about individuals, attention has been paid almost exclusively to general intelligence, as reflected in a composite intelligence quotient, or IQ. That is, a single number, embodied in the IQ, is used to portray an individual's mental ability. Option D: Sensory function testing involves assessment of pain, light-touch sensation, and temperature discrimination. Assessment of sensory function helps to identify the different pathways for light touch, proprioception, vibration, and pain. Use a pinprick to evaluate pain sensation.
A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half-circle. To document the client's gait, the nurse should use which term? A. Ataxic B. Dystrophic C. Helicopod D. Steppage
Correct Answer: C. Helicopod A helicopod gait is an abnormal gait in which the client's feet make a half circle with each step. A gait seen in some conversion reactions or hysteric disorders, in which the feet describe half circles. Option A: An ataxic gait is staggering and unsteady. Most commonly seen in cerebellar disease, this gait is described as clumsy, staggering movements with a wide-based gait. While standing still, the patient's body may swagger back and forth and from side to side, known as titubation. Patients will not be able to walk from heel to toe or in a straight line. Option B: In a dystrophic gait, the client waddles with the legs far apart. Movement of the trunk is exaggerated to produce a waddling, duck-like walk. Progressive muscular dystrophy or hip dislocation present from birth can produce a waddling gait. Option D: In a steppage gait, the feet, and toes raise high off the floor and the heel comes down heavily with each step. Seen in patients with foot drop (weakness of foot dorsiflexion), the cause of this gait is due to an attempt to lift the leg high enough during walking so that the foot does not drag on the floor.
A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client's history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury
Correct Answer: C. Intestinal obstruction Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Pyridostigmine bromide is preferred over neostigmine because of its longer duration of action. In those with bromide intolerance that leads to gastrointestinal effects, ambenonium chloride can be used. Patients with MuSK MG respond poorly to these drugs and hence may require higher doses. Option A: Ulcerative colitis is not a contraindication to pyridostigmine. The mainstay of treatment in MG involves cholinesterase enzyme inhibitors and immunosuppressive agents. Symptoms that are resistant to primary treatment modalities or those requiring rapid resolution of symptoms (myasthenic crisis), plasmapheresis, or intravenous immunoglobulins can be used. Option B: Blood dyscrasia is not a contraindication to pyridostigmine. Agricultural employees who handle organophosphates for a prolonged period should have medical monitoring. Appropriate testing is recommended to identify overexposure before the occurrence of clinical illness. Both serum and RBC cholinesterase must be determined. Option D: The contraction of the smooth muscle in various organs of the body gets mediated through M3 receptors. Tone and peristalsis in the gastrointestinal tract increase and sphincters relax, causing abdominal cramps and evacuation of the bowel. The detrusor muscle contracts while the bladder trigone and sphincter relax, leading to the voiding of the bladder.
A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Diencephalon B. Medulla C. Midbrain D. Cortex
Correct Answer: C. Midbrain Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons. Option A: Extensive lesions involving the forebrain, diencephalon, or rostral midbrain are known to cause decorticate posturing. This includes the motor cortex, premotor cortex, corona radiata, internal capsule, and thalamus. Decorticate posturing is described as abnormal flexion of the arms with the extension of the legs. Specifically, it involves slow flexion of the elbow, wrist, and fingers with adduction and internal rotation at the shoulder. The lower limbs show extension and internal rotation at the hip, with the extension of the knee and plantar flexion of the feet. Toes are typically abducted and hyperextended. Option B: Damage to the medulla results in flaccidity. Small changes or injury to the medulla can lead to paraplegia, cardiovascular and respiratory dysfunction, or vagus nerve injury. The medulla oblongata is the connection between the brainstem and the spinal cord, carrying multiple important functional centers. It comprises the cardiovascular-respiratory regulation system, descending motor tracts, ascending sensory tracts, and origin of cranial nerves IX, X, XI, and XII. Option D: With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Synonymous terms for decorticate posturing include abnormal flexion, decorticate rigidity, flexor posturing, or decorticate response. Brain lesions of several anatomical regions may cause both postures, though they do usually involve some degree of brainstem injury. It is, however, accepted that decorticate typically requires an injury more rostral than decerebrate posturing.
Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech
Correct Answer: C. Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may depress liver function or cause idiosyncratic hepatitis. The intravenous administration of dantrolene in healthy volunteers has resulted in skeletal muscle weakness, dyspnea, respiratory muscle weakness, and decreased inspiratory capacity. These are expected symptoms given the mechanism of action of the medication. Option A: For those taking the oral capsule for muscle spasticity, liver function tests require monitoring, and dantrolene discontinued if signs and symptoms of liver injury appear. These include elevated LFTs, jaundice, right upper quadrant pain, etc. These symptoms typically resolve upon the discontinuation of dantrolene. If dantrolene is to be reinstated, per recommendations, the patient should be inpatient, and the drug initiated in very small doses with gradual increases. Option B: Although urine retention is an adverse reaction associated with dantrolene use; they aren't as common as muscle weakness. When using the lyophilized form of dantrolene, large volumes of sterile water are administered with the medication. Although mannitol is included with the dantrolene, monitoring fluid status and output is paramount to the ongoing care of resuscitation of these patients. Option D: Muscle weakness is rarely severe enough to cause slurring of speech, drooling, and enuresis. Oral dantrolene carries a black box warning for the potential for hepatotoxicity, including overt hepatitis. Hepatic function should be evaluated before the administration of the oral capsule form and require monitoring throughout the course of treatment. The medication should stop immediately if liver function becomes impaired.
A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client's oculocephalic (doll's eye) response by: A. Introducing ice water into the external auditory canal. B. Touching the cornea with a wisp of cotton. C. Turning the client's head suddenly while holding the eyelids open. D. Shining a bright light into the pupil.
Correct Answer: C. Turning the client's head suddenly while holding the eyelids open. To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client's head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The oculocephalic reflex (doll's eyes reflex) is an application of the vestibular-ocular reflex (VOR) used for neurologic examination of cranial nerves 3, 6, and 8, the reflex arc including brainstem nuclei, and overall gross brainstem function. Option A: The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client's eyes deviate to the side of ice water introduction. Vestibulo-ocular reflex is an involuntary reflex that stabilizes the visual field and retinal image during head motion by producing eye movements in a counter direction. Option B: The nurse touches the client's cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. The corneal blink reflex is caused by a loop between the trigeminal sensory nerves and the facial motor (VII) nerve innervation of the orbicularis oculi muscles. The reflex activates when sensory stimulus contacts either free nerve endings or mechanoreceptors within the epithelium of the cornea. Option D: Shining a bright light into the client's pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting. The oculomotor nerve helps to adjust and coordinate eye position during movement. Several movements assist with this process: saccades, smooth pursuit, fixation, accommodation, vestibulo-ocular reflex, and optokinetic reflex.
Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal? A. More back pain than the first postoperative day. B. Paresthesia in the dermatomes near the wounds. C. Urine retention or incontinence. D. Temperature of 99.2° F (37.3° C).
Correct Answer: C. Urine retention or incontinence. Urine retention or incontinence may indicate cauda equina syndrome, which requires immediate surgery. Cauda equina syndrome (CES) results from compression and disruption of the function of these nerves and can be inclusive of the conus medullaris or distal to it, and most often occurs when damage occurs to the L3-L5 nerve roots. Option A: An increase in pain on the second postoperative day is common because the long-acting local anesthetic, which may have been injected during surgery, will wear off. The role of the nurse in the postoperative period should include finite management of intravenous fluids, foley catheter care until ambulating, administering antibiotics, pain control, wound/dressing care, encouraging patient ambulation, and advance diet when appropriate. Option B: While paresthesia is common after surgery, progressive weakness or paralysis may indicate spinal nerve compression. Related-technique complications are associated with the underlying structures covered by the laminae, being the dural sac tear and nerve roots injury the most common. These complications occur more often in elderly patients due to the fragility of the dural sac. Also, the severity of compression could be a factor that increases the rate of a dural tear; the most common risk factor for dural tear is the reoperation due to the presence of scar tissue. Option D: A mild fever is also common after surgery but is considered significant only if it reaches 101° F (38.3° C). Postoperative wound infection and wound dehiscence are other complications to consider, the presence of wound erythema, increased pain, or swelling may raise the suspicion of wound infection.
A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. "Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours." B. "Try to ambulate independently after about 24 hours." C. "Shampoo your hair every day for ten (10) days to help prevent ear infection." D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."
Correct Answer: D. "Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days." For 30 days after a stapedectomy, the client should avoid air travel, sudden movements that may cause trauma, and exposure to loud sounds and pressure changes (such as from high altitudes). The goal of any stapes procedure is to restore the vibration of fluids within the cochlea; increasing communication secondary to increasing sound amplification, bringing hearing levels to acceptable thresholds. Option A: Immediately after surgery, the client should lie flat with the surgical ear facing upward; nose blowing is permitted but should be done gently and on one side at a time. The primary goal when operating on the stapes is to re-establish sound transmission through an ossicular chain that has likely been stiffened through the disease process known as otosclerosis. Otosclerosis, an otic capsule disease that involves absorption of compact bone and the redeposition of spongy-appearing, or spongiotic, bone, is the most common cause of acquired conductive hearing loss (CHL) as a result of stapes fixation. Option B: The client's first attempt at postoperative ambulation should be supervised to prevent falls caused by vertigo and light-headedness. Skilled post-anesthesia care unit nurses are invaluable in the immediate postoperative period, as stapedectomy patients may experience pain, vertigo with nausea and vomiting (the latter posing a risk to prosthesis dislodgement), and facial nerve weakness. These nurses play a crucial role in notifying the surgeon of any early-onset complications associated with the procedure. Option C: The client must avoid shampooing and swimming to keep the dressing and the ear dry. A terrible complication of stapes surgery is the formation of reactive granulation tissue in and around the oval window. There are many ideas on what causes such a reaction, but it is believed that the use of powderless gloves, the avoidance of Gelfoam, or washing the prosthesis before introducing it into the middle ear space has reduced granulomatous formations, postoperatively.
The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform? A. Sit with the client for a few minutes. B. Administer an analgesic. C. Inform the nurse manager. D. Call the physician immediately.
Correct Answer: D. Call the physician immediately. A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately. Unruptured cerebral aneurysms are asymptomatic and are therefore unable to be detected based on history and physical exam alone. However, when ruptured, they commonly present with a sudden onset, severe headache. This is classically described as a "thunderclap headache" or "worst headache of my life." In 30% of patients, the pain is lateralized to the side of the aneurysm. Option A: Sitting with the client is appropriate but only after the physician has been notified of the change in the client's condition. A headache may be accompanied by a brief loss of consciousness, meningismus, or nausea and vomiting. Seizures are rare, occurring in less than 10% of patients. Sudden death may also occur in 10% to 15% of patients. Option B: The physician will decide whether or not an administration of an analgesic is indicated. The decision to treat is multifactorial and depends on the size, location, age, and comorbidities of the patient, as well as whether or not there is a rupture. The treatment can be divided into 2 categories: surgical and endovascular. Option C: Informing the nurse manager isn't necessary. Interestingly, 30% to 50% of patients with major SAH report a sudden and severe headache 6 to 20 days prior. This is referred to as a "sentinel headache," which represents a minor hemorrhage or "warning leak."
A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client's therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification? A. Parasympathomimetic agent B. Sympatholytic agent C. Adrenergic blocker D. Cholinergic blocker
Correct Answer: D. Cholinergic blocker Atropine sulfate is a cholinergic blocker. It isn't a parasympathomimetic agent, a sympatholytic agent, or an adrenergic blocker. Atropine is an antimuscarinic that works through competitive inhibition of postganglionic acetylcholine receptors and direct vagolytic action, which leads to parasympathetic inhibition of the acetylcholine receptors in smooth muscle. Option A: Parasympathomimetics are a class of pharmacological agents that activate the parasympathetic division of the autonomic nervous system. These drugs work by mimicking or modifying the effects of acetylcholine (ACh), the primary neurotransmitter of the parasympathetic nervous system. Parasympathomimetic medications are classified into two main categories based on whether they are direct agonists or indirect agonists of ACh. Option B: Methyldopa is a centrally acting sympatholytic agent used in the treatment of hypertension. Alpha-methyldopa is converted to methyl norepinephrine centrally to decrease the adrenergic outflow by alpha-2 agonist action from the central nervous system, leading to reduced total peripheral resistance and decreased systemic blood pressure. Option C: The effects of the sympathetic nervous system can be blocked either by decreasing sympathetic outflow from the brain, suppressing release of norepinephrine from terminals, or by blocking postsynaptic receptors. Adrenergic antagonists reduce the effectiveness of sympathetic nerve stimulation and the effects of exogenously applied agonists, such as isoproterenol. Most often the receptor antagonists are divided into ?-receptor antagonists and ?-receptor antagonists.
During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once each shift. This assessment evaluates: A. Cranial nerves I and II. B. Cranial nerves III and V. C. Cranial nerves VI and VIII. D. Cranial nerves IX and X.
Correct Answer: D. Cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerve IX (glossopharyngeal nerve), is responsible for motor (SVE) innervation of the stylopharyngeus and the pharyngeal constrictor muscles by the nucleus ambiguus. Damage to the recurrent laryngeal branch of the vagus nerve can result in vocal hoarseness or acute dyspnea with bilateral avulsion. Option A: Cranial nerves I, II, and VIII don't possess motor functions. Cranial nerve I, the olfactory nerve, is composed of special visceral afferents (SVA). Chemo-sensory receptors in the olfactory mucosal lining bind to odorant molecules and conduct a signal through the nerves traveling through the cribriform plate of the ethmoid bone to synapse on the neurons of the olfactory bulb within the cranial vault. Cranial nerve II, the optic nerve, conveys special somatic afferent (SSA) visual sensory information from the rods and cones retinal sensory receptors to the thalamus, especially the lateral geniculate nucleus (LGN), and the superior colliculus (SC). Cranial nerve III innervates most of the eye muscles, by splitting into a superior and an inferior branch to innervate the remaining three recti muscles, the inferior oblique, and the skeletal muscle component of levator palpebrae superiors. Option B: The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. Cranial nerve III innervates most of the eye muscles, by splitting into a superior and an inferior branch to innervate the remaining three recti muscles, the inferior oblique, and the skeletal muscle component of levator palpebrae superioris. While no autonomic fibers travel with the fifth cranial nerve as it exits the pons, parasympathetic fibers from the other mixed cranial nerves will join with peripheral branches of cranial nerve V to innervate their respective target structures, such as the lacrimal, parotid, submandibular, and sublingual glands. Option C: The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement. The abducens nerve innervates the lateral rectus muscles only; thereby this nerve can be tested by evaluating the abduction of the eye gaze. Cranial nerve VIII, the vestibulocochlear nerve, is responsible for the auditory sense and the vestibular sense of orientation of the head.
While reviewing a client's chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn't be used; pancuronium may be used in a lower dosage. C. Pancuronium shouldn't be used; succinylcholine may be used in a lower dosage. D. Pancuronium and succinylcholine both require cautious administration.
Correct Answer: D. Pancuronium and succinylcholine both require cautious administration. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Patients on NMDA are usually in the intensive care unit. Monitoring of patients on NMDA includes pulse oximetry for oxygen saturation, continuous end-tidal C02. The rise in the level of carbon dioxide might show the development of malignant hyperthermia. Option A: Such a client isn't less sensitive to the effects of a neuromuscular blocking agent. Succinylcholine administration correlates to a significant rise in the serum potassium. Therefore, it is recommended to avoid use of succinylcholine in patients with chronic renal disease, burn patients, patients with crush injuries, and rhabdomyolysis. Elevated potassium level can lead to fatal arrhythmia. Option B: Succinylcholine is also associated with bradycardia especially in the pediatric population. The stimulation of the nicotinic receptor activates a muscarinic receptor that produces bradycardia. The effect can be blunted by administering atropine or glycopyrrolate. Option C: Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis. When an electric impulse transmits along the motor neuron, it causes the release of acetylcholine (ACh) from the presynaptic membrane which travels across the synaptic cleft and acts on the nicotinic receptors on the postsynaptic membrane, causing muscle contraction.
A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for: A. Long-term treatment of epilepsy. B. Postoperative pain management of laminectomy clients. C. Postoperative pain management of diskectomy clients. D. Treatment of spasticity associated with spinal cord lesions.
Correct Answer: D. Treatment of spasticity associated with spinal cord lesions. In addition to relieving painful muscle spasms, Diazepam also is recommended for treatment of spasticity associated with spinal cord lesions. Diazepam's use is limited by its central nervous system effects and the tolerance that develops with prolonged use. It is a fast-acting, long-lasting benzodiazepine commonly used in the treatment of anxiety disorders, as well as alcohol detoxification, acute recurrent seizures, severe muscle spasm, and spasticity associated with neurologic disorders. Option A: The parenteral form of diazepam can treat status epilepticus, but the drug's sedating properties make it an unsuitable choice for long-term management of epilepsy. Diazepam HAs FDA approval for the management of anxiety disorders, short-term relief of anxiety symptoms, spasticity associated with upper motor neuron disorders, adjunct therapy for muscle spasms, preoperative anxiety relief, management of certain refractory epilepsy patients and adjunct in severe recurrent convulsive seizures, and an adjunct in status epilepticus. Option B: Diazepam is not used for pain management. Specifically, the allosteric binding within the limbic system leads to the anxiolytic effects seen with diazepam. Allosteric binding within the spinal cord and motor neurons is the primary mediator of the myorelaxant effects seen with diazepam. Mediation of the sedative, amnestic, and anticonvulsant effects of diazepam is through receptor binding within the cortex, thalamus, and cerebellum. Option C: Diazepam isn't an analgesic agent. Benzodiazepines have largely replaced barbiturates in the treatment of anxiety and sleep disorders because of their improved safety profile, fewer side effects, and the availability of the antagonist flumazenil to reverse oversedation and benzodiazepine intoxication.
