A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior.
-
Solution
Affect is flat, with periods of emotional lability
The limbic system is responsible for feelings (affect) and emotions.
Option A: The cerebral hemispheres, with specific regional functions, control orientation.
Option C: Recall of recent events is controlled by the hippocampus.
Option D: Calculation ability and knowledge of current events relates to the function of the frontal lobe.
A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure client to ensure client safety?
-
Solution
Provide a clear path for ambulation without obstacles
Cranial nerve II is the optic nerve, which governs vision. The nurse can provide safety for the visually impaired client by clearing the path of obstacles when ambulating.
Option A: Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two-thirds and posterior third of the tongue, respectively.
Option B: Testing the shower water temperature would be useful if there were an impairment of peripheral nerves.
A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
-
Solution
Providing information, giving positive feedback, and encouraging relaxation
The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client’s condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of:
-
Solution
Respiratory or gastrointestinal infection during the previous month.
Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, the syndrome can be triggered by vaccination or surgery.
The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:
-
Solution
Exposure to cold and drafts
Exposure to cold or drafts is avoided. Local application of heat to the face may improve blood flow and provide comfort.
Options B and C: Prevention of muscle atrophy with Bell’s palsy is accomplished with facial massage, facial exercises, and electrical stimulation of the nerves.
A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:
-
Solution
Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem
Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.
The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
-
Solution
Taking medications on time to maintain therapeutic blood levels
Taking medications correctly to maintain blood levels that are not too low or too high is important.
Option A: Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
Option B: Muscle-strengthening exercises are not helpful and can fatigue the client.
Option C: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength.
A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
-
Solution
Omitting doses of medication
Myasthenic crisis often is caused by under medication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger
Options A and D: Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger a myasthenic crisis.
Option B: Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications.
Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?
-
Solution
Completing the sentences that the client cannot finish
Clients with aphasia after brain attack (stroke) often fatigue easily and have a short attention span. The nurse would avoid shouting (because the client is not deaf), appearing rushed for a response, and letting family members provide all the responses for the client.
Options A, B, and D: General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner.
The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:
-
Solution
Consistently uses adaptive equipment in dressing self
Clients are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
Options A, B, and C are not adaptive behaviors.
The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?
-
Solution
Giving the client thin liquids
Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned.
Option B: Liquids are thickened to avoid aspiration.
Option C: Food is placed on the unaffected side of the mouth.
Option D: The client is assisted with meals as needed and is given ample time to chew and swallow.
The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:
-
Solution
The client has weakness on the right side of the body, including the face and tongue.
Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is a weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition.
Options C and D: The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse is caring for the male client who begins to experience seizure activity while in beD. Which of the following actions by the nurse would be contraindicated?
-
Solution
Restraining the client’s limbs
The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
Options A, C, and D: Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage.
A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
-
Solution
Limiting bladder catheterization to once every 12 hours
The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every four (4) to six (6) hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
Option A: Constipation and fecal impaction are other causes, so maintaining bowel regularity is important.
A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:
-
Solution
Separates into concentric rings and test positive of glucose
Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.