Chapter 61: Nursing Management: Chronic Neurological Problems Flashcards Preview

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Flashcards in Chapter 61: Nursing Management: Chronic Neurological Problems Deck (33)
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1

A patient with a headache describes it as affecting both sides of his head with a moderate intensity that becomes worse when he is physically active. The nurse knows that the patient’s clinical manifestations are characteristic of which of the following disorders?
a. Cluster headaches
b. Migraine headaches
c. Tension-type headaches
d. Headaches associated with trigeminal neuralgia

ANS: C
The International Headache Society (2004) classification system defines tension-type headache as involving at least two of the following characteristics: pressure or tightness sensation, mild to moderate severity, bilateral location, or worsening with physical activity.

2

A 20-year-old woman is seen at the health clinic with a severe migraine headache. The headaches began 3 months ago, and she has had four headaches since that time. During assessment, the patient tells the nurse she is afraid to make social plans because she never knows when she will be incapacitated with the pain. What is the most appropriate nursing intervention in response to the patient’s comments?
a. Refer the patient for counselling to assist her with conflict resolution and stress reduction.
b. Suggest that the patient keep a diary of headache episodes to identify precipitating factors.
c. Encourage the patient to learn the holistic techniques of meditation and biofeedback to minimize the pain.
d. Reassure the patient that the headaches are not serious and the pain can be controlled with a variety of drugs.

ANS: B
The initial nursing action should be further assessment of the precipitating causes of the headaches, quality and location of pain, and so on, which can be accomplished by the patient keeping a diary of the headache episodes.

3

When teaching a patient about management of her migraine headaches, the nurse determines that teaching has been effective when the patient gives which of the following responses?
a. “I will take the topiramate as soon as any headaches start.”
b. “The sumatriptan will help increase the blood flow to my brain.”
c. “I will try to lie down someplace dark and quiet when the headaches begin.”
d. “A glass of wine might help me relax and prevent headaches from developing.”

ANS: C
It is recommended that the patient with a migraine rest in a dimly lit, quiet area

4

What is the most important nursing tool in diagnosing a cluster headache?
a. Magnetic resonance imaging (MRI) of the brain
b. Electromyography
c. The patient history
d. Computed tomography (CT) imaging of the brain

ANS: C
Diagnosis of cluster headache is made primarily on the basis of the patient’s symptoms; therefore, a thorough patient history is required.

5

A patient experiences cluster headaches that occur about every year for 2 months. During assessment of the patient during an episode of the headache, what would the nurse expect to find?
a. Nuchal rigidity
b. Nausea and vomiting
c. Unilateral eyelid edema and ptosis
d. A severe, throbbing, bilateral headache


ANS: C
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches.

6

Which one of the following should the nurse teach the patient to avoid because it may trigger a headache?
a. Tylenol
b. Popsicles
c. Hot dogs
d. Fried chicken

ANS: C
Patients should be taught to avoid foods containing amines, nitrates, vinegar, onions, or MSG. Hot dogs contain nitrates.

7

When caring for a patient with epilepsy who was hospitalized and successfully treated for status epilepticus, what is a precaution that the nurse should institute as part of the care?
a. Placing oxygen and suction equipment at the bedside
b. Assigning an assistant to stay with the patient at all times
c. Keeping a tongue blade available to insert in case of a seizure
d. Instructing the patient to stay in bed and call for assistance to go to the bathroom

ANS: A
Oxygen and suction equipment should be available at the bedside for a patient who has epilepsy.

8

A patient has a tonic–clonic seizure while the nurse is in the patient’s room. During the seizure, what is it important for the nurse to do?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patient’s arms and legs to prevent injury during the seizure.
c. Avoid touching the patient to prevent further stimulation of the nervous system.
d. Time the seizure, and observe and record the details of the seizure and the postictal phase.

ANS: D
Because diagnosis and treatment of seizures are frequently based on the description of the seizure, recording the length and details of the seizure is important.

9

The nurse witnesses a patient with a seizure disorder as he suddenly jerks his arms and legs, falls to the floor, and regains consciousness immediately. What type of seizure is demonstrated by this patient that the nurse must document?
a. An atonic seizure
b. A myoclonic seizure
c. A complex partial seizure with automatisms
d. A simple partial seizure with motor symptoms

ANS: A
An atonic (“drop attack”) seizure involves either a tonic episode or a paroxysmal loss of muscle tone and begins suddenly with the person falling to the ground. Consciousness usually returns by the time the person hits the ground, and normal activity can be resumed immediately.

10

After experiencing a generalized tonic–clonic seizure in the classroom, a 25-year-old high school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries when told of the diagnosis and tells the nurse that she can never go back to teaching after experiencing the seizure in front of her students. What is an appropriate nursing diagnosis for the patient?
a. Anxiety related to loss of control during seizures
b. Hopelessness related to diagnosis of chronic illness
c. Disturbed body image related to new diagnosis of epilepsy
d. Ineffective role performance related to misinformation about epilepsy

ANS: D
The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication.

11

Following recovery from a stroke, a 68-year-old patient developed complex partial seizures with motor symptoms beginning in the right arm with progression to unconsciousness. The physician prescribes phenytoin (Dilantin) for control of the seizures. Which of the following statements by the patient indicates understanding of what self-care related to this drug includes?
a. “I should use soft swabs rather than a toothbrush to clean my mouth.”
b. “If I have a seizure, I should call an ambulance to take me to the hospital.”
c. “I will take the medication at the beginning of the seizure before I lose consciousness.”
d. “As I start this medication, I will need to have my blood taken frequently to check the level of the drug.”

ANS: D
Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved.

12

When a patient experiences a generalized tonic–clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?
a. Send patient to radiology department for a CT scan.
b. Administer midazolam (Versed).
c. Check capillary blood glucose.
d. Monitor level of consciousness.

ANS: B
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines.

13

A patient found in a tonic–clonic seizure reports, after gaining consciousness, that the seizure was preceded by numbness and tingling of the arm. What does the nurse know that this finding indicates?
a. An absence seizure
b. A simple partial seizure
c. A complex partial seizure
d. A generalized myoclonic seizure

ANS: C
The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. In addition, an alteration in consciousness is always manifested.

14

A patient has newly diagnosed multiple sclerosis (MS) and asks many questions about the disease. When teaching the patient about MS, what should the nurse explain?
a. MS is an untreatable viral disease that destroys the basal ganglia in the brain.
b. Nerve impulses travel too quickly over nerves that have lost their myelin coat, overloading the brain.
c. An autoimmune process causes gradual destruction of the myelin sheath of nerves in the brain and spinal cord.
d. In MS, antibodies are produced against acetylcholine receptors, resulting in blocked muscle contraction.

ANS: C
The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission.

15

When the nurse is obtaining a health history from a patient undergoing diagnostic testing for MS, which of the following is a finding identified as characteristic of early MS?
a. Memory lapses
b. Intermittent fever
c. Constipation
d. Weakness of the legs

ANS: D
Extremity weakness or spasms are common motor symptoms of MS

16

A 28-year-old woman has had MS for 3 years and wants to have children before her disease becomes worse. When she asks about the risks associated with pregnancy, the nurse should explain which of the following information?
a. The stress of pregnancy is likely to accelerate the course of the disease.
b. She may experience an acute, long-lasting exacerbation of the disease during pregnancy.
c. Because MS is genetically transmitted, she should consider the risks to future generations.
d. MS has no apparent effect on pregnancy and lactation, but the risk for an exacerbation after the pregnancy is increased.

ANS: D
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms.

17

A patient with MS is to begin treatment with glatiramer acetate (Copaxone). In planning the patient teaching necessary with the use of the drug, the nurse recognizes the patient will need to be taught which of the following information?
a. Self-injection techniques for subcutaneous injections
b. To use contraceptive methods other than oral contraceptives for birth control
c. To plan laboratory monitoring of complete blood count, chemistries, and liver function every 3 months
d. That the drug will control symptoms but has no effect on the progression of the disease

ANS: A
Glatiramer acetate is administered by self-injection

18

According to the International Classification of Seizure Disorders, what would be the classification of a clonic seizure?
a. Simple partial
b. Generalized
c. Complex partial
d. Unclassified

ANS: B
A clonic seizure is classified as a generalized seizure.

19

A patient with MS has a nursing diagnosis of urinary retention related to sensorimotor deficits. What is an appropriate nursing intervention for this problem?
a. Decrease fluid intake in the evening.
b. Teach the patient how to use the Credé manoeuvre.
c. Suggest the use of incontinence briefs for nighttime use only.
d. Assist the patient to the commode every 2 hours during the day.

ANS: B
The Credé manoeuvre can be used to improve bladder emptying

20

The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson’s disease. To assist the patient to ambulate safely, what should the nurse do?
a. Allow the patient to ambulate only with assistance.
b. Teach the patient to rock back and forth to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to slide the feet forward with each step, always keeping the feet in contact with the floor.

ANS: B
Rocking the body from side to side stimulates balance and improves mobility.

21

For which classification of drug that is used in the treatment of MS does the nurse know to teach the patient about the importance of restricting their sodium intake?
a. Cholinergics
b. Acetylcholinesterase
c. Corticosteroids
d. Anticholinergics

ANS: C
Patient teaching with the administration of corticosteroids includes restricting salt intake, not stopping therapy abruptly, and being aware of drug interactions

22

A patient with Parkinson’s disease has decreased tongue mobility and an inability to move his facial muscles. The nurse documents which of the following nursing diagnoses that reflects these impairments?
a. Disuse syndrome related to loss of muscle control
b. Self-care deficit related to bradykinesia and rigidity
c. Impaired verbal communication related to difficulty swallowing
d. Impaired oral mucous membranes related to inability to swallow saliva

ANS: C
The inability to use the tongue and facial muscles decreases the patient’s ability to socialize or communicate needs.

23

A patient with Parkinson’s disease tells the nurse that she is having increasing problems with constipation. The nurse explains that constipation occurring with Parkinson’s disease is most often a result of which of the following factors?
a. Advanced age
b. Decreased physical activity
c. Side effects of dopaminergic agents
d. Diminished nerve conduction to the bowel

ANS: B
Promotion of physical exercise and a well-balanced diet are major concerns for nursing care. Exercise for patients with Parkinson’s disease can limit the consequences of decreased mobility, such as muscle atrophy, contractures, and constipation

24

Which of the following is a clinical manifestation of myasthenia gravis (MG)?
a. Bulging eyes
b. Scotoma
c. Unstable gait
d. Hypertension

ANS: C
A clinical manifestation of MG is unstable or unusual gait

25

A patient with MG is admitted to the hospital with severe weakness and acute respiratory insufficiency. The physician performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor which of the following?
a. Pupillary size
b. Muscle strength
c. Respiratory function
d. Level of consciousness

ANS: C
The Tensilon test in a patient with MG reveals improved muscle contractility after intravenous injection of the anticholinesterase agent edrophonium chloride (Tensilon); therefore, respiratory function must be monitored. (Anticholinesterase blocks the enzyme acetylcholinesterase.) This test also aids in the diagnosis of cholinergic crisis (secondary to overdose of anticholinesterase medication). In this condition, Tensilon does not improve muscle weakness but may actually increase it. Atropine, a cholinergic antagonist, should be readily available to counteract Tensilon effects when it is used diagnostically

26

When teaching a patient with MG about management of the disease, the nurse advises the patient to do which of the following?
a. Anticipate the need for weekly plasmapheresis treatments.
b. Protect the extremities from injury due to poor sensory perception.
c. Do frequent weight-bearing exercise to prevent muscle atrophy.
d. Perform necessary physically demanding activities in the morning.

ANS: D
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then.

27

A patient with MG has a nursing diagnosis of altered nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals, the patient should avoid which of the following actions?
a. Writing letters
b. Talking on the telephone
c. Typing on the computer
d. Taking pyridostigmine (Mestinon)

ANS: B
The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals.

28

A patient with restless legs syndrome (RLS) tells the nurse, “My leg pain and twitching keep me awake so much of the night, I am tired most of the day. Is there anything I can do?” Based on this information, which nursing diagnosis is most appropriate?
a. Ineffective role performance related to fatigue
b. Chronic pain related to RLS
c. Anxiety related to lack of knowledge about RLS treatment
d. Sleep deprivation related to leg pain and involuntary movement

ANS: D
The patient’s statement indicates that daytime fatigue caused by lack of sleep is the major concern

29

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a. Observing for agitation and paranoia
b. Assisting the patient with active range of motion (ROM)
c. Using simple words and phrases to explain procedures
d. Administering muscle relaxants as needed for muscle spasms

ANS: B
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible.

30

A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease. When teaching the patient and her family about this disorder, what should the nurse explain about Huntington’s disease?
a. It is characterized by retarded voluntary and involuntary movement, resulting in immobility.
b. Genetic testing is available to determine the risk for your children.
c. It can be controlled by replacing the neurotransmitters acetylcholine and -aminobutyric acid.
d. It will result in limited physical and mental deterioration, requiring some planning and support for care.

ANS: B
Genetic testing is available to determine whether an asymptomatic individual has the Huntington’s disease gene. The patient and family should be informed of the benefits and problems associated with genetic testing.