ch 64 neuro infections, autnoimmune, neuropathies

Question 1

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

Answer 1

neck flexion produces flexion of knees and hips

Question 2

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

Answer 2

washing the face

Question 3

the nurse is caring for a client with multiple sclerosis. the client tells the nurse the hardest thigh to deal with is the fatigue. when teaching the client how to reduce fatigue, what action should the nurse suggest?

Answer 3

resting in an air conditioned room whenever possible

Question 4

a client with Guillian Barre syndrome has experienced a sharp decline in vital capacity. what is the nurse’s most appropriate actions?

Answer 4

prepare to assist with intubation

Question 5

a client diagnosed with bell palsy is being cared for on an outpatient basis. during health education, the nurse should promote which of the following actions?

Answer 5

applying a protective eye shield at night

Question 6

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

Answer 6

MS is a progressive demyelinating disease of the nervous system

Question 7

the nurse is creating a plan of care for a client who has a recent diagnosis of MS. which of the following should the nurse include in the client’s care plan?

Answer 7

instruct the client on daily muscle stretching

Question 8

a client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. what principle applies to the administration of this medication?

Answer 8

the client should be monitored for bone marrow depression

Question 9

a client presents to the clinic reporting a headache. the nurse notes that the client is guarding the neck and tells the nurse about stiffness in the neck area. the nurse suspects the client may have meningitis. what is another well-recognized sign of the infection

Answer 9

positive Kernig sign

Question 10

the nurse is developing a plan for care for a client newly diagnosed with bell palsy. the nurse’s plan for care should address what characteristic manifestation of this disease?

Answer 10

facial paralysis

Question 11

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

Answer 11

vocal paralysis

Question 12

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

Answer 12

a low motor neuron lesion

Question 13

a client with suspected creutzfedlt-Jakob disease is being admitted to the unit. the nurse would expect what diagnostic test to be ordered for this client?

Answer 13

EEG

Question 14

to alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. what health education should the nurse provide to the client before initiating this treatment?

Answer 14

blood levels of the drug must be monitored

Question 15

a client with HSV has been admitted to the ICU. what medication would the nurse expect the health care provider to order for the treatment of this disease process?

Answer 15

acyclovir

Question 16

a middle aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. what sign or symptom is most likely to have prompted the client to seek care?

Answer 16

difficulty in coordination

Question 17

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

Answer 17

in the morning, with frequent rest periods

Question 18

a 33 year old client presents at the clinic with reports of weakness, in coordination, dizziness, and loss of balance. the client is hospitalized and diagnosed with MS. what sign or symptom, revealed during the initial assessment, is typical of MS?

Answer 18

blurred vision, intention tremor, and urinary hesitancy

Question 19

the nurse is developing a plan of care for a client with Guillian-Barre syndrome. which of the following interventions should the nurse prioritized for this client?

Answer 19

using the incentive spirometer as prescribed

Question 20

a 69 year old client is brought to the ED by ambulance because a family member found the client lying on the floor disoriented and lethargic. the health care provider suspects bacterial meningitis and admits the client to the ICU. what interventions should the nurse perform? select all that apply.

Answer 20

-administer antipyretics as prescribed.
-perform frequent neurologic assessements
-monitor paint levels and administer analgesics

Question 21

the critical care nurse is charging for 25 year old admitted to the icu with a brain abscess. what is a priority nursing responsibility in the care of this client?

Answer 21

monitoring neurologic status closely

Question 22

a client is being admitted to the neurologist ICU with suspected HSV. what nursing action best addresses the client’s reported headache?

Answer 22

dimming the lights and reducing stimulation

Question 23

a client is admitted through the ed with suspected St. Louis encephalitis. the unique clinical feature of this condition will make what nursing action a priority?

Answer 23

close monitoring of fluid balance

Question 24

the nurse is caring for a 77 year old client with MS. the client is very concerned about the progress of the disease and what the future holds. the nurse should know that older adult clients with MS are known to be particularly concerned about what variables? select all that apply.

Answer 24

-possible nursing home placement
-increasing disability
-becoming a burden on the family

Question 25

the clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. the client has begun treatment parity pyridostigimine bromide. what change in status would most clearly suggest a therapeutic benefit of this medication?

Answer 25

increased muscle strength

Question 26

the critical care nurse is admitting a client in myasthenia crisis to the ICU. the nurse should prioritize what nursing action in the immediate care of this client?

Answer 26

providing ventilatory assistance

Question 27

the nurse caring for a client in ICU diagnosed with Guillian Barre syndrome should prioritize monitoring for what potential complication?

Answer 27

autonomic dysfunction

Question 28

the nurse is teaching a client with Guillian Barre syndrome about the disease. the client asks how the client can ever recover if demyelination of the nerves is occurring. what would be the nurse’s best response?

Answer 28

GB spares the Schwann cell, which allows for demyelination in the recovery phase of the disease

Question 29

a client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange for a myasthenic exacerbation. the nurse should anticipate what therapeutic response?

Answer 29

symptom improvement that lasts a few weeks after TPE ceases

Question 30

the nurse is discharging a client home after surgery for trigeminal neuralgia. what advice should the nurse provide to this client in order to reduce the risk of injury?

Answer 30

avoid rubbing the eye on the affected side of the face

Question 31

a client diagnosed with bell palsy is having decreased sensitivity to touch of the involved nerve. what should the nurse recommend to prevent atrophy of the muscles?

Answer 31

whistling

Question 32

a client with diabetes presents to the clinic and is diagnosed with mononneuropathy. this client’s nursing care should involve which of the following?

Answer 32

protection of the affected limb from injury

Question 33

a client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. included in the admission orders is baclofen. what should the nurse identify as an expected outcome for this treatment?

Answer 33

decreased muscle spasms in the lower extremities

Question 34

a 73 year old client comes to the clinic reporting weakness and loss of sensation in the feet and legs. assessment of the client shows decreased reflexes bilaterally. why would it be a challenge to diagnose a peripheral neuropathy in this client?

Answer 34

many symptoms can be the result of normal aging process

Question 35

a client with MS has developed dysphasia as a result of cranial nerve dysfunction. what nursing action should the nurse consequently perform?

Answer 35

position the client upright during feeding

Question 36

a 48 year old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. the nurse should recognize what implication of this diagnosis?

Answer 36

the client needs to be assessed for MS

Question 37

a client presents at the clinic with the pain and weakness in the hands. on assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. the nurse knows that these findings are indicative of what condition?

Answer 37

peripheral nerve disorder