Diseases
The nurse notes documentation that a postcraniotomy client is having difficulty with body image. The nurse determines that the client is still working on the postoperative outcome criteria when the client indicates which altered personal appearance?
A. Wears a turban to cover the incision
B. Indicates that facial puffiness will be a permanent problem
C. Verbalizes that periorbital bruising will disappear over time
D. States an intention to purchase a hairpiece until the hair has grown back
B. Indicates that facial puffiness will be a permanent problem
After craniotomy, the client may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss, which are temporary. The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.
The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?
A. Allergy to pollen
B. Previous back injury
C. History of headaches
D. History of hypertension
A. Allergy to pollen
Previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. In addition, an allergy to pollen would not place the client at risk for a neurological problem.
The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention would the nurse plan to incorporate into the care routine for the client?
A. Discouraging the family from touching the client
B. Explaining equipment and procedures on an ongoing basis
C. Ensuring adherence to visiting hours to ensure the client's rest
D. Encouraging the family not to "give in" to their feelings of grief
B. Explaining equipment and procedures on an ongoing basis
Families often need assistance to cope with the sudden, severe illness of a loved one. The nurse can help the family of an unconscious client by assisting them to work through their feelings of grief. The nurse should explain all equipment, treatments, and procedures, and supplement or reinforce information given by the primary health care provider. The family should be encouraged to touch and speak to the client and to become involved in the client's care to the extent that they are comfortable. The nurse should allow the family to stay with the client as much as possible and should encourage them to eat and sleep adequately to maintain their strength.
The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which would the nurse check before the procedure?
A. Claustrophobia
B. Excessive weight
C. Allergy to salmon
D. Allergy to iodine or shellfish
A client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.
D. Allergy to iodine or shellfish
The nurse is providing care to a client with increased intracranial pressure (ICP). Which approaches would be beneficial in controlling the client's ICP from an environmental viewpoint? Select all that apply.
A. Reducing environmental noise
B. Maintaining a calm atmosphere
C. Allowing the client uninterrupted time for sleep
D. Clustering nursing activities to be done all at once
E. Keeping overhead lights on most of the day and night
A. Reducing environmental noise
B. Maintaining a calm atmosphere
C. Allowing the client uninterrupted time for sleep
Nursing interventions should be spaced out over the shift to minimize the risk of a rise in ICP. If possible, activities known to raise ICP should be avoided when possible. Other interventions to control the ICP include keeping the lighting in the room dim or off; maintaining a calm, quiet environment; and avoiding emotional stress and interruption of sleep.
The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement?
A. "I will wash my face with cotton pads."
B . "I'll have to start chewing on the unaffected side."
C. "I should rinse my mouth if tooth brushing is painful."
D. "I will try to eat my food either very warm or very cold."
D. "I will try to eat my food either very warm or very cold."
Facial pain can be minimized by using cotton pads and room temperature water to wash the face. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If tooth brushing triggers pain, sometimes an oral rinse after meals is more helpful.
The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs and symptoms of infection. The nurse understands that there may be damage to the client's thermoregulatory center which is located in which part of the brain?
A. Cerebrum
B. Cerebellum
C. Hippocampus
D. Hypothalamus
D. Hypothalamus
Hypothalamic damage causes hyperthermia, which may also be called "central fever." It is characterized by a persistent high fever with no diurnal variation. There is also an absence of sweating. Options 1, 2, and 3 are not associated with temperature regulation.
A client is somewhat nervous about having magnetic resonance imaging (MRI). Which statement by the nurse would provide reassurance to the client about the procedure?
A. "You will be able to eat before the procedure unless you get nauseated easily. If so, you should eat lightly."
B. "The MRI machine is a long, hollow narrow tube, and may make you feel somewhat claustrophobic."
C. "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."
D. "It is necessary to remove any metal or metal-containing objects before having the MRI done to avoid the metal being drawn into the magnetic field."
C. "Even though you are alone in the scanner, you will be in voice communication with the technologist during the procedure."
The MRI scanner is a hollow tube, which gives some clients a feeling of claustrophobia. Metal objects must be removed before the procedure so that they are not drawn into the magnetic field. The client may eat and take all prescribed medications before the procedure. If a contrast medium is used, the client may wish to eat lightly if there is a tendency to get nauseated easily. The client lies supine on a padded table, which moves into the imager. The client must lie still during the procedure. The imager makes tapping noises while scanning. The client is alone in the imager, but the nurse can reassure the client that the technician is in voice communication with the client at all times during the procedure.
A client receives a dose of edrophonium. The client shows improvement in muscle strength for a period of time following the injection. The nurse would interpret this finding as indicative of which disease process?
A. Multiple sclerosis
B. Myasthenia gravis
C. Muscular dystrophy
D. Amyotrophic lateral sclerosis
B. Myasthenia gravis
Myasthenia gravis can often be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium. This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds to receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine, also may be used because its effect lasts for 1 to 2 hours, providing a better analysis. For either medication, atropine sulfate should be available as the antidote.
The nurse is assisting in caring for a client who sustained a traumatic head injury following a motor vehicle crash. The nurse documents that the client is exhibiting decerebrate posturing. The nurse bases this documentation on which observation?
A. Flexion of the extremities and pronation of the arms
B. Extension of the extremities and pronation of the arms
C. Upper extremity flexion with lower extremity extension
D. Upper extremity extension with lower extremity flexion
B. Extension of the extremities and pronation of the arms
Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brainstem area, consists of extension of the extremities and pronation of the arms. Posturing is a late sign of deterioration in the client's neurological status and warrants immediate primary health care provider notification.
The nursing instructor asks a nursing student about the points to document if the client has had a seizure. The instructor determines that the student needs to research seizures and related documentation points if the student states which assessment is important?
A. Duration of the seizure
B. Changes in pupil size or eye deviation
C. Seizure progression and type of movements
D. Client's diet in the 2 hours preceding seizure activity
D. Client's diet in the 2 hours preceding seizure activity
Typically, seizure assessment includes the time the seizure began, part(s) of the body affected, the type of movements and progression of the seizure, changes in pupil size, eye deviation or nystagmus, client condition and vital signs during the seizure, and postictal status.
A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which findings noted in the client history indicates that the client may be ineligible for this diagnostic procedure? Select all that apply.
A. Hypertension
B. Hip replacement
C. Permanent pacemaker
D. Prosthetic valve replacement
E. Chronic obstructive pulmonary disorder
B. Hip replacement
C. Permanent pacemaker
D. Prosthetic valve replacement
The client having an MRI must have all metallic objects removed because of the magnetic field generated by the device. A careful history is done to determine if any metal objects are inside the client, such as orthopedic hardware, pacemakers, artificial heart valves, aneurysm clips, or intrauterine devices. These may heat up, become dislodged, or malfunction during this procedure. The client may be ineligible if there is significant risk.
The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will perform which activity?
A. Sit in soft, deep chairs.
B. Exercise in the evening to combat fatigue.
C. Rock back and forth to start movement slowly.
D. Buy clothes with many buttons to maintain finger dexterity.
C. Rock back and forth to start movement slowly.
The client with Parkinson's disease should exercise in the morning, when energy levels are highest. The client should avoid sitting in soft, deep chairs because getting up from them can be difficult. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to allow for easier dressing.
The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement?
A. "Here's the Medic-Alert bracelet I obtained."
B. "I should take my medications an hour before mealtime."
C. "Resting in a sauna will be a relaxing form of activity."
D. "I've made arrangements to get a portable resuscitation bag and home suction equipment.
C. "Resting in a sauna will be a relaxing form of activity."
Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. Taking medications 1 hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should carry medical identification about the condition. The client should avoid activities that could worsen the symptoms, including stress, infection, heat (including saunas, staying out of the sun at the beach), surgery, or alcohol.
A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?
A. Squeezing rubber balls
B. Doing push-ups in a prone position
C. Extending the arms while holding weights
D. Doing active range of motion to finger joints
D. Doing active range of motion to finger joints
Range-of-motion exercises of the finger joints prevent contractures but do not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper.
An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets which finding as abnormal if present?
A. Protein
B. Glucose
C. Red blood cells
D. White blood cells
C. Red blood cells
The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3/mm3). Protein (15 to 45 mg/dL) and glucose (40 to 80 mg/dL) are normally present in CSF.
The nurse observes that a client with Parkinson's disease has very little facial expression. The nurse attributes this piece of data to which information?
A. Masklike facies is a component of Parkinson's disease.
B. The client does not want her emotional reaction to the disease to show.
C. Clients with Parkinson's disease have diminished emotional involvement.
D. Clients with Parkinson's disease act very much like schizophrenics in that they have very little affect.
A. Masklike facies is a component of Parkinson's disease.
A masked facial expression is typical of the client with Parkinson's disease. There are no data to support the assumption provided in option 2. Option 3 is not a true statement. Option 4 places a false interpretation on the client's expression.
A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply.
A. Double vision
B. Excessive tearing
C. Inability to furrow brow
D. Pain in cheek, jaw, and teeth
E. Altered level of consciousness
F. A lag in closing the bottom eyelid
B. Excessive tearing
C. Inability to furrow brow
F. A lag in closing the bottom eyelid
Excessive tearing and an inability to furrow the brow are signs of Bell's palsy. The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. Double vision and altered level of consciousness are signs of a cerebrovascular accident (CVA). Paroxysms of excruciating pain are seen with trigeminal neuralgia.
The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply
A. "I should not suddenly stop taking this medication."
B. "Alcohol is not contraindicated while taking this medication."
C. "Good oral hygiene is needed, including brushing and flossing."
D. "The medication dose may be self-adjusted, depending on side effects."
E. "The morning dose of the medication should be taken before a sample for a serum drug level is drawn."
A. "I should not suddenly stop taking this medication."
C. "Good oral hygiene is needed, including brushing and flossing."
Typical anticonvulsant medication instructions include taking the prescribed dose daily to keep the blood level of the drug constant, having a serum drug level drawn before taking the morning dose, avoiding abruptly stopping the medication, avoiding alcohol, checking with the primary health care provider before taking over-the-counter medications, avoiding activities in which alertness and coordination are required until medication effects are known, providing good oral hygiene and getting regular dental care, and wearing a Medic-Alert bracelet or tag.
Family members of an elderly client ask the nurse if there is any test to determine if a person will eventually get Alzheimer's disease. Which appropriate response would the nurse make?
A. "A radionuclide imaging (brain scan) test can predict Alzheimer's disease."
B. "A magnetic resonance imaging (MRI) scan can tell if a person will get Alzheimer's disease."
C. "A positron emission tomography (PET) scan can be a test to determine if a person will get Alzheimer's disease."
D. "There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."
D. "There are no tests to determine if a person will get Alzheimer's disease, but research for new diagnostic tests will continue."
Currently there are no diagnostic tests for providers to use in making the diagnosis of preclinical Alzheimer's disease. But research does continue. The other tests are used for diagnosing other cognitive or neurological disorders.