Question 1

The nurse is concerned that a patient recovering from a thymectomy is developing a pneumothorax. What did the nurse assess to cause this concern?

Accepted Answer

Shortness of breath, decreased breath sounds, and sudden onset of chest pain are classic signs of pneumothorax. These symptoms indicate a potential complication following a thymectomy, as air may enter the pleural space, causing lung collapse.

Question 2

The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the primary focus of care for this patient?

Accepted Answer

The primary focus of care for a patient with ALS is respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communicate. Pain management and ROM exercises may be important secondary priorities, but respiratory support is the main concern. Giving immunosuppressants is not indicated in the management of ALS. Providing gastrostomy feedings is important for nutrition, but it is not the primary focus of care.

Question 3

The husband of a patient with Alzheimer disease (AD) asks the nurse to explain sundowning. How should the nurse respond to this question?

Accepted Answer

Sundowning is a term used to describe a common symptom in patients with Alzheimer disease in which they become more agitated, disoriented to time, and may wander during the afternoon or early evening. It is important to monitor patients during these hours to ensure their safety.

Question 4

A patient is prescribed tetrabenazine (Xenazine) for treatment of chorea caused by Huntington disease. What should the nurse emphasize when teaching the patient and family about this medication?

Accepted Answer

The answer of A patient is prescribed tetrabenazine (Xenazine) for...

Question 5

A patient with stage 2 Alzheimer disease becomes very agitated in the evenings. What would be an appropriate nursing intervention for the nurse to use for this patient?

Accepted Answer

Playing soft music in the patient's room can have a calming effect and help reduce agitation, especially in the evenings when symptoms of Alzheimer's can worsen, a phenomenon known as "sundowning."

Question 6

A patient with myasthenia gravis is prescribed pyridostigmine (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report?

Accepted Answer

The answer of A patient with myasthenia gravis is prescribed...

Question 7

The nurse is caring for a patient recovering from a percutaneous rhizotomy for trigeminal neuralgia. What techniques should the nurse use to assess this patient for adverse effects from the procedure?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 8

The nurse is reviewing the medical record of a patient with Alzheimer disease. Which stage should the nurse realize this patient is experiencing? \[\begin{array} { | l | l | l | } 
\hline\text { Time }&\text {Body Systems  }&\text { Charting } \
\hline 0800 & \text { Cognition } & \begin{array} { l } 
\text { Cliented to person, states he is "in the } \
\text { linic" but does not know the name or } \
\text { location;; looks at clock and states the } \
\text { correct time; unable to repeat serial 7s or } \
\text { add 2 numbers }
\end{array} \
\hline 0900 & \text { Visuospatial } & \begin{array} { l } 
\text { Puts on shirt and pants but unable to fasten } \
\text { them; puts on his slippers; reaches for } \
\text { utensils on the breakfast tray but cannot } \
\text { accurately locate them }
\end{array} \
\hline 1000 & \text { Gross motor } & \text { Pacing in room; appears restless } \
\hline 1400&\text { Personality }&\begin{array} { l } 
\text { Agitation has gradually increased since } \
\text { midmorning; describes seeing his daughter } \
\text { walking on the sidewalk in front of the } \
\text { building }
\end{array} \
\hline 1600 & \text {Decision-making } &\text { Unable to make choices of aftemoon } \
\hline&& \begin{array} { l } 
\text { recreational therapy activities }
\end{array} \
\hline
\end{array}\]

Accepted Answer

Based on the patient's symptoms and behaviors, the nurse should realize that the patient is experiencing stage 5 of Alzheimer's disease. This stage is characterized by significant cognitive decline, including difficulty with basic activities of daily living, wandering and getting lost, and increasing confusion and disorientation. The patient's inability to make choices and increasing agitation also suggest a later stage of the disease.

Question 9

The nurse is reviewing laboratory reports for a patient. What health problem should the nurse realize this patient is experiencing? $$\begin{array}{ | l | l | } 
\hline\text { Laboratory Results }\
\hline \text { Edrophonium chloride (Tensilon) } & \text { Positive (for } 4.5 \text { minutes) } \
\hline \text { Single-fiber electromyography } & \text { Delayed nerve transmission } \
\hline \text { Serum acetylcholine receptor antibodies } & \text { Elevated levels }\
\hline
\end{array}$$

Accepted Answer

The positive result of edrophonium chloride (Tensilon) test, delayed nerve transmission indicated by single-fiber electromyography, and elevated serum acetylcholine receptor antibodies all point towards the diagnosis of myasthenia gravis, an autoimmune disorder characterized by muscle weakness and fatigue. Parkinson's disease, ALS, and GBS do not have these specific laboratory findings.

Question 10

The nurse is completing discharge teaching to a patient with a new diagnosis of multiple sclerosis (MS). What does the nurse recommend about diet?

Accepted Answer

Maintaining a healthy weight is important for managing MS symptoms and improving overall health. Eating a balanced diet with a variety of foods from all food groups can help achieve and maintain a healthy weight. It is not recommended to increase fats or lower carbohydrates, as there is no evidence to support this for managing MS. Dysphagia may occur in later stages of MS, but it is not a common symptom in the early stages of the disease. Therefore, including foods that are easy to swallow is not a priority in the initial stages of MS.

Question 11

The nurse is caring for a patient with Guillain-Barré syndrome. Which medication should the nurse expect to provide to this patient?

Accepted Answer

The answer of The nurse is caring for a patient...

Question 12

The nurse is assessing cranial nerve function in the patient recovering from percutaneous rhizotomy of the facial nerve. What technique should the nurse use when making this assessment?

Accepted Answer

The correct technique for assessing cranial nerve function, specifically the facial nerve (Cranial Nerve VII), after a percutaneous rhizotomy involves evaluating the muscles of facial expression. Asking the patient to blow out the cheeks, wrinkle the forehead, frown, wink, and close both eyes tightly assesses the function of the facial nerve effectively.

Question 13

During an assessment the nurse becomes concerned that a patient is demonstrating early manifestations of amyotrophic lateral sclerosis. What findings did the nurse use to make this clinical determination?

Accepted Answer

The answer of During an assessment the nurse becomes concerned...

Question 14

The nurse is preparing a patient for plasmapheresis. In which order should the nurse complete the following actions? Standard Text: Click and drag the options below to move them up or down.
A) Check with physician about holding medications. 
B) Assess vital signs and weight. 
C) Verify blood type and crossmatch for replacement blood products. 
D) Assess for dizziness or hypotension. 
E) Assess intravenous port for bruising. 
F) Reevaluate laboratory data, especially CBC, platelet count, and clotting times.
G) none of the above

Accepted Answer

The answer of The nurse is preparing a patient for...

Question 15

The nurse is completing teaching to a patient with a new diagnosis of Bell palsy. What should be a priority focus of this teaching?

Accepted Answer

Bell palsy often affects facial nerves, leading to difficulty in blinking or closing the eyelid on the affected side, which necessitates a focus on eye care to prevent dryness or injury.

Question 16

After returning from a plasmapheresis treatment, the nurse suspects that a patient with myasthenia gravis is demonstrating signs of electrolyte imbalances. What did the patient demonstrate to confirm the nurse's suspicion?

Accepted Answer

The answer of After returning from a plasmapheresis treatment, the...

Question 17

A patient is being admitted for treatment of trigeminal neuralgia. Place an X on the body part on which the nurse should focus the assessment for this health problem.

Accepted Answer

The answer of A patient is being admitted for treatment...

Question 18

The nurse suspects that a patient has Parkinson disease. What did the nurse assess as early signs of this neurologic disease?

Accepted Answer

The answer of The nurse suspects that a patient has...

Question 19

The nurse is caring for a patient with trigeminal neuralgia. What should the nurse expect the treatment focus to be for this health problem?

Accepted Answer

Trigeminal neuralgia is a condition characterized by severe facial pain. The treatment focus for this health problem involves drugs such as tricyclic anticonvulsants or surgery to sever the nerve root (rhizotomy) in severe cases. Antiviral drugs or other therapies would not be effective in treating this condition. Respiratory support and NSAIDs also would not be relevant in treating trigeminal neuralgia. Physical therapy and warm, moist packs may offer some relief, but are not the primary focus of treatment.

Quiz 44: Nursing Care of Patients With Neurologic Disorders