Ch. 61
The nurse is providing care for a client who is unconscious. What nursing intervention takes highest priority?
Maintaining a patent airway
Maintaining a patent airway always takes top priority!
A nurse is communicating with a client who has aphasia after having a stroke. What action should the nurse take?
Face the client and establish eye contact.
When speaking with a client who has aphasia, the nurse should face the client and establish eye contact. The nurse should use short phrases, not one long sentence, and give the client time between phrases to understand what is being said. Keeping extraneous and background noise such as the television to a minimum helps the client concentrate on what is being said. It isn't necessary to speak in a louder or softer voice than normal.
Which nursing intervention can help a client maintain healthy skin?
Keeping the client well hydrated.
Keeping the client well hydrated helps prevent skin cracking and infection because intact healthy skin is the body's first line of defense. To help a client maintain healthy skin, the nurse should avoid strong or harsh detergents and should use mild soap. The nurse shouldn't remove adhesive tape quickly because this action can strip or scrape the skin. The nurse should recommend wearing loose-fitting — not tight-fitting — clothes in hot weather to promote heat loss by evaporation.
Name of a Degenerative neurologic disorder?
Huntington disease
Huntington disease is a chronic, progressive, degenerative neurologic and hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia.
A patient suffering a stroke is having a difficult time swallowing. What would the nurse document this finding as?
Dysphagia
Stroke can result in dysphagia (difficulty swallowing) due to impaired function of the mouth, tongue, palate, larynx, pharynx, or upper esophagus. Patients must be observed for paroxysms of coughing, food dribbling out of or pooling in one side of the mouth, food retained for long periods in the mouth, or nasal regurgitation when swallowing liquids. Swallowing difficulties place the patient at risk for aspiration, pneumonia, dehydration, and malnutrition.
What medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
Anticonvulsants are used to decrease the risk of postoperative seizures following cranial surgery. Diuretics, corticosteroids, and antianxiety medications may be used for the client with increased intracranial pressure.
A client is experiencing dysphagia following a stroke. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?
Help the client sit upright when eating and feed slowly.
Having the client sit upright, preferably out of bed in a chair, and instructing him or her to tuck the chin toward the chest when swallowing will help prevent aspiration. The client may be started on a thick liquid or puréed diet, because these foods are easier to swallow than thin liquids. The diet may be advanced as the client becomes more proficient at swallowing. If the client cannot resume oral intake, a gastrointestinal feeding tube is placed for ongoing tube feedings and medication administration. The client should be allowed to rest before meals because fatigue may interfere with coordination and following instructions.
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside?
Intubation tray and suction apparatus
Progressive GBS can move to the upper areas of the body and affect the muscles of respiration. If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. A spirometer is used to evaluate the client's ventilation capacity. A blood pressure apparatus, nebulizer, and thermometer are not required because generally a client with GBS does not show signs of increased blood pressure or temperature.
A nurse is providing care to a client with Parkinson's disease. The nurse understands the client's signs and symptoms are related to a depletion of which of the following?
Dopamine
Parkinson's disease is associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglion region. The loss of dopamine stores results in more excitatory neurotransmitters (acetylcholine) than inhibitory transmitters (dopamine). Serotonin and norepinephrine are not involved.
Which is an indicator of orthostatic hypotension?
Dizziness
Indicators of orthostatic hypotension include a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.
A client with meningitis has a history of seizures. What activity should the nurse do while the client is actively seizing?
Turn the client to the side during a seizure and do not restrain movements.
When a client is in a seizure, the nurse should turn the client to the side and not restrain his or her movements. This helps reduce the potential for aspiration of saliva or stomach contents. The nurse should suction the mouth and pharynx after a seizure has occurred, not during the seizure. Anticonvulsants may be administered to reduce the chances of seizure. Oxygen should not be given to clients with seizures. Clients with respiratory distress are given oxygen. Finally, a cooling blanket is placed beneath the client when hyperthermia occurs, not a seizure.
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. What is a risk factor that can be modified?
Hypertension
Modifiable risk factors for ischemic stroke include hypertension, atrial fibrillation, hyperlipidemia, diabetes mellitus, smoking, asymptomatic carotid stenosis, obesity, and excessive alcohol consumption. Non-modifiable risk factors include advanced age, gender, and race.
A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
Placement of a feeding tube
Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube may need to be placed if the deficit is prolonged and if the client is unable to eat. Clients with severe dysphagia have difficulty swallowing and are at risk for aspiration. A feeding tube would be placed to address this deficit.
The nurse is providing discharge teaching to a client with a spinal cord tumor and instructs the client to avoid hot water bottles and heating blankets for what reason?
Impaired sensory perception
Clients with residual sensory involvement are cautioned about the dangers of extremes in temperature. They should be educated about the dangers of heating devices (e.g., hot water bottles, heating pads, space heaters) as their sensory integration may be impaired, causing them to lose the ability to detect dangerous stimulations and to react appropriately. Discharge teaching for motor weakness involves learning different ways to manage activities of daily living and possible teaching regarding the use of assistive devices such as a cane. Medications used in the treatment of spinal tumors would not predispose the client to diminished sensory integration; this problem arises from brain structure and spinal cord compression. Although cognitive impairment may be sequelae resulting from the growth and treatment of brain and spinal tumors, the primary reason clients are instructed not to use excessive temperatures is because they may have lost of ability to sense extremes of hot and cold.
Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome?
3 hours
Rapid diagnosis of stroke and initiation of thrombolytic therapy (within 3 hours) in clients with ischemic stroke lead to a decrease in the size of the stroke and an overall improvement in functional outcome after 3 months.
The nurse is caring for a client who has been admitted with a head injury and continually assesses for signs of increasing intracranial pressure (ICP). The earliest sign of increasing ICP is
Change in level of consciousness
The earliest sign of increasing ICP is a change in level of consciousness. Other early indicators are slowing of speech and delay in response to verbal suggestions. The other three choices are all parts of a clinical phenomenon known as the Cushing's response, which is a late sign of increasing ICP.
A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?
Avoid heavy lifting.
A client with an aneurysm should be advised to avoid heavy lifting, extreme emotional situations, or straining of stools because they may increase intracranial pressure and thereby headaches. Such clients should be advised against taking opioid analgesics or including peanut butter, bread, or tart foods in the diet, because these foods cause choking. Herbal medications should be taken only in consultation with the physician.
A patient who has experienced a stroke is learning to use a cane to ambulate. The patient has left-sided weakness. After teaching the patient about using the cane, the nurse determines that the patient has understood the instructions when stating that using the cane on the right is done for which purpose?
To distribute weight away from the affected side
Holding a cane on the uninvolved side distributes weight away from the involved side. Holding the cane close to the body prevents leaning. Using a cane won't promote a long stride length or reduce the risk of edema.
Reflect on nursing interventions for a client with post-polio syndrome?
The nurse provides care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client.
No specific medical or surgical treatment is available for this syndrome and therefore nursing plays a pivotal role in the team approach to assisting clients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Nursing interventions are aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the client. Clients need to plan and coordinate activities to conserve energy and reduce fatigue. Important activities should be planned for the morning as fatigue often increases in the afternoon and evening. Pain in muscles and joints may be a problem. Nonpharmacologic techniques such as the application of heat and cold are most appropriate because these clients tend to have strong reactions to medications.
Corticosteroids are used in the management of brain tumors to
reduce cerebral edema.
Corticosteroids may be used before and after treatment to reduce cerebral edema and promote a smoother, more rapid recovery. Corticosteroids do not prevent extension of the tumor or facilitate regeneration of neurons. Stereotactic procedures identify the precise location of the tumor.
A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?
Elevate the head of the bed 30 degrees.
To facilitate venous drainage and avoid jugular compression, the nurse should generally elevate the head of the bed 30 degrees. Clients with increased ICP poorly tolerate suctioning and should not be suctioned on a regular basis. Turning the client from side to side increases the risk of jugular compression and increases in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.
A client diagnosed with migraine headaches asks the nurse what to do to help control the headaches and minimize the number of attacks the client is having. What instructions should the nurse give this client?
Identify and avoid factors that precipitate or intensify an attack.
The nurse includes the following instructions: Follow the indications and dosage regimen for medication and notify the physician of any adverse drug effects. Identify and avoid factors that precipitate or intensify an attack. Keep a food diary, which may help identify foods that trigger attacks. Keep a record of the attacks, including activities before the attack and environmental or emotional circumstances that appear to bring on the attack. Lie down in a darkened room and avoid noise and movement when an attack occurs, if that is possible.
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
Muscle spasms
Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.
A client has just returned from surgery after undergoing a lumbar laminectomy. Which of the following would be most important to do when positioning the client in bed?
Using a logrolling motion to change positions
After a laminectomy, logrolling is used to change the client's position. When in bed, a pillow is placed under the client's head and the knee rest is elevated slightly to relax the back muscles. When lying on his or her side, extreme knee flexion is avoided. Sitting is discouraged except for defecation.
What medication is the most effective agent in the treatment of Parkinson disease?
Levodopa
Levodopa is the most effective agent and is the mainstay of treatment for Parkinson disease (PD). Benztropine, amantadine, and bromocriptine mesylate are utilized in the treatment of PD but are not the most effective.