Brainiac
The nurse correlates which data as placing a patient at risk for experiencing a metabolic seizure?
A. Serum magnesium 3.2 mg/dL
B. Serum calcium 14 mg/dL
C. Serum potassium 3.2 mEq/L
D. Serum sodium 115 mEq/L
D. Serum sodium 115 mEq/L
Hyponatremia and hypernatremia are associated
with metabolic seizures. This is a decreased sodium level; the normal range is 135 to 145 mEq/L.
The nurse assesses the patient for which early finding in ALS?
A. Bowel and bladder incontinence
B. Respiratory distress
C. Muscle cramps
D. Paralysis
C. Muscle cramps
Upper and lower neurons degenerate and die. Unable to function, muscles gradually weaken, atrophy, and twitch (fasciculate).
Muscle weakness is an early sign of this progressive disease.
A patient is diagnosed with myasthenia gravis (MG). What information does the nurse include in an explanation of this disease process?
A. “Your nerve endings are no longer functional and that leads to muscle weakness.”
B. “Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction.”
C. “Your body does not make enough of the neurotransmitter needed for movement.”
D. “Your nerves have lost their protective covering and impulses are not as smooth.”
B. “Your body has a disorder that destroys receptor sites at the neuromuscular junction, leading to decreased nerve conduction.” In MG, circulating anti-AChR antibodies bind with the AChR, resulting in complement-mediated destruction of receptor sites.
In assessing a patient with increased intracranial pressure, the nurse notes that the patient’s left pupil is larger than the right pupil. The nurse correlates the larger left pupil to compression of which cranial nerve?
A. Left optic nerve
B. Left oculomotor nerve
C. Right optic nerve
D. Right oculomotor nerve
B. Left oculomotor nerve
Compression of the third cranial nerve (oculomotor) produces pupillary dilation on the same side as the cranial nerve compression or ipsilateral to the cranial nerve compression.
A patient being evaluated for Guillain-Barré syndrome (GBS) presents with bilateral symmetrical muscle weakness and sensory changes of both feet and legs. The nurse correlates which key finding to this disease process?
A. Areflexia
B. Hyperreflexia
C. Hypothermia
D. Hyperanalgesia
A. Areflexia
After the first few days of weakness, neurological assessment demonstrates diminished or absent deep tendon reflexes (areflexia). Areflexia is recognized as a key finding in GBS.
The nurse correlates the clinical finding of aphasia to damage to which cerebral artery?
A. Anterior cerebral artery
B. Basilar artery
C. Middle cerebral artery
D. Posterior cerebral artery
C. Middle cerebral artery
Decreased blood flow through the middle cerebral artery results in contralateral motor and sensory deficits, speech and language deficits, and aphasia.
A patient recently diagnosed with amyotrophic lateral sclerosis is having difficulty with swallowing and has been choking and coughing excessively at mealtimes. The nurse implements which action first?
A. Initiating low-flow oxygen therapy
B. Suctioning the oropharynx
C. Auscultating breath sounds
D. Assessing neurological status
C. Auscultating breath sounds
The priority is to assess the airway and breathing. Because motor weakness involves muscles of the face, mouth, and neck, maintaining an intact airway is compromised. Airway compromise is greater as the patient demonstrates weakened cough and impaired swallowing.
A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. How should the nurse respond about the pathophysiology of the disorder?
A. “An infection destroys the nerve endings.”
B. “An infection enters the spinal cord and erodes the nerves at the roots.”
C. “The nerves are killed by infiltration of your body’s white blood cells used to fight an infection.”
D. “The covering of nerves that help conduct impulses is damaged.”
D. “The covering of nerves that help conduct impulses is damaged.”
In GBS, the patient’s own immune system begins to destroy the myelin that surrounds the peripheral nerves. Destruction occurs between the nodes of Ranvier that results in slowing of impulses or conduction block. There is infiltration of lymphocytes into the peripheral nervous system, which attracts macrophages; the macrophages penetrate the Schwann cells and invade the myelin, resulting in demyelination.
The nurse is preparing a patient for insertion of an intraventricular catheter intracranial pressure (ICP) monitoring device. What is an advantage of this device?
A. Must be inserted in the operating room
B. Catheter tip located in the lateral ventricle
C. Less mechanical drift of the measurement over time
D. Lower rate of infection because of no fluid reservoir
B. Catheter tip located in the lateral ventricle
The intraventricular catheter ICP monitoring device is considered the gold standard for ICP measurement because the catheter tip is located in the lateral ventricle. It allows measurement of ICP as well as drainage of cerebrospinal fluid (CSF).
The nurse monitors for which clinical manifestation in the patient diagnosed with trigeminal neuralgia?
A. Acute onset of pain
B. Impaired swallowing
C. Visual disturbances
D. Impaired extraocular movements
A. Acute onset of pain
Trigeminal neuralgia is a pain disorder, and the patient seeks medical attention for relief. It is not unusual for the patient to present to a primary care practitioner with a chief complaint of shocklike facial pain that is sharp and throbbing.