UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
1. A client with a 2, 3, 5
T4 spinal cord in- Clients with a high (T6 or above) spinal cord injury are at risk for autonom-
jury has a se- ic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic
vere throbbing nervous system stimulation. Classic signs include hypertension (up to 300 mm
headache and Hg systolic), throbbing headache, diaphoresis above the level of injury, brady-
appears flushed cardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea. This
and diaphoret- is a life-threatening condition that requires immediate intervention to prevent
ic. Which prior- complications (eg, hypertensive stroke, seizures).
ity interventions
should the nurse Clients with a spinal cord injury should have their blood pressure checked when
perform? Select all they report a headache (Option 3). The most common cause of autonomic dysre-
that apply. flexia is bladder irritation due to distention. The client needs to be catheterized or
the possibility of a kink in the existing catheter must be assessed (Option 2). Bowel
1. Administer an impaction can also be a cause; a digital rectal examination should be performed.
analgesic as need- Constrictive clothing should be removed to decrease skin stimulation (Option 5).
ed The primary health care provider should be notified. An alpha-adrenergic blocker
2. Determine if or an arteriolar vasodilator (eg, nifedipine) may be prescribed.
there is bladder
distention (Option 1) Headaches associated with autonomic dysreflexia are typically due to
3. Measure the severe hypertension and often resolve after blood pressure has been treated.
client's blood (Option 4) The client should have the head of the bed elevated 45 degrees or
pressure high Fowler's to lower blood pressure. The Sims' position is flat and side-lying.
4. Place the client
Educational objective:Autonomic dysreflexia is a life-threatening condition in a
in the Sims' posi-
client with high spinal cord injury. Classic signs/symptoms include severe hyper-
tion
tension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerec-
5. Remove con-
tion. Emergency treatment includes correcting the cause (check bowel or bladder
strictive clothing
distention), removing tight clothing, and raising the
2. The nurse is car- 1
ing for a young Huntington disease (HD) is an incurable autosomal dominant hereditary disease
adult who is con- that causes progressive nerve degeneration, which results in impaired movement,
https://www.stuvia.com/user/actualstudy Page 1
,UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
sidering becom- swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like move-
ing pregnant. The ment) is a hallmark sign. The onset of active disease is usually at age 30-50, and
client expresses death from neuromuscular and respiratory complications typically occurs within
concern, stating, 20 years of diagnosis.
"One of my par-
ents has Hunting- HD is confirmed by genetic testing. Clients who have a parent with HD and are
ton disease, and I considering having biological children should receive genetic counseling (Option
am afraid my child 1).
will get it." How
should the nurse
Educational objective: Huntington disease is an incurable autosomal dominant
respond?
disease that causes progressive nerve degeneration, which impairs movement,
swallowing, speech, and cognitive abilities. Death typically occurs within 20 years.
1. "Genetic coun-
Clients who have a parent with this disease should receive genetic counseling,
seling is recom-
especially when planning to start a family.
mended. You will
receive a refer-
ral before you
leave."
2. "Huntington
disease inheri-
tance requires
both biological
parents to carry
the gene."
3. "There are oth-
er ways to grow
your family. You
should consider
adoption."
4. "This dis-
ease occurs spon-
taneously and is
https://www.stuvia.com/user/actualstudy Page 2
, UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
not likely to affect
your children."
3. The nurse is as- 2, 3, 4
sessing a client
with advanced Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurode-
amyotrophic lat- generative disease with no cure. ALS causes progressive degeneration of motor
eral sclerosis. neurons in the brain and spinal cord. Physical symptoms include fatigue, pro-
Which of the gressive muscle weakness, twitching and muscle spasms, difficulty swallowing,
following assess- difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients
ment findings survive only 3-5 years after the diagnosis as there is no cure.
does the nurse
Treatment focuses on symptom management. Interventions include:
expect? Select all
- Respiratory support with noninvasive positive pressure (eg, bilevel positive air-
that apply.
way pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy)
1. Diarrhea - Feeding tube for enteral nutrition
2. Difficulty - Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dys-
breathing pnea)
3. Difficulty swal- - Mobility assistive devices (eg, walker, wheelchair)
lowing - Communication assistive devices (eg, alphabet boards, specialized computers)
4. Muscle weak-
(Option 1) Constipation due to decreased mobility is more common in ALS.
ness
Diarrhea is not seen.
5. Resting tremor
(Option 5) Resting tremor is characteristic of parkinsonism.
Educational objective: Amyotrophic lateral sclerosis causes motor neuron degen-
eration that leads to progressive muscle weakness, twitching and muscle spasms,
difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure.
Treatment focuses on symptom management.
4. The nurse is 3
caring for a
client diagnosed GBS is an acute, immune-mediated polyneuropathy that is most often accom-
https://www.stuvia.com/user/actualstudy Page 3
, UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
with Guillain-Bar- panied by ascending muscle weakness and absent deep-tendon reflexes. Many
ré syndrome clients have a history of antecedent respiratory tract or GI infection. Lower-ex-
(GBS) after a tremity weakness progresses over hours to days to involve the thorax, arms, and
recent gastroin- cranial nerves. However, neuromuscular respiratory failure is the most life-threat-
testinal (GI) ill- ening complication.
ness. Monitoring
for which of the Early signs indicating impending respiratory failure include:
following is a Inability to cough
nursing care pri- Shallow respirations
ority for this Dyspnea and hypoxia
client? Inability to lift the head or eye brows
1. Diaphoresis Assessing the client's pulmonary function by serial spirometry is also recommend-
with facial flush- ed. Measurement of forced vital capacity (FVC) is the gold standard for assessing
ing ventilation; a decline in FVC indicates impending respiratory arrest requiring
2. Hypoactive endotracheal intubation.
or absent bowel
(Option 1) Severe autonomic dysfunction can present as diaphoresis and facial
sounds
flushing.
3. Inability to
(Option 2) The client with GBS is also at risk for paralytic ileus, which is related to
cough or lift the
either immobility or nerve damage. As a result, the nurse should monitor for the
head
presence hypoactive/absent bowel sounds.
4. Warm, tender,
(Option 4) Clients with GBS are at risk of developing deep venous thrombosis due
and swollen leg
to lack of ambulation and should receive pharmacologic prophylaxis (heparin)
and support stockings.
Although symptoms in options 1, 2, and 4 represent a progressive illness and are
important to communicate to the health care provider promptly, they are not the
highest priority compared to impending respiratory failure.
Educational objective: Respiratory distress is a potential complication of pro-
gressing paralysis in clients with Guillain-Barré syndrome. The nurse should
https://www.stuvia.com/user/actualstudy Page 4
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
1. A client with a 2, 3, 5
T4 spinal cord in- Clients with a high (T6 or above) spinal cord injury are at risk for autonom-
jury has a se- ic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic
vere throbbing nervous system stimulation. Classic signs include hypertension (up to 300 mm
headache and Hg systolic), throbbing headache, diaphoresis above the level of injury, brady-
appears flushed cardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea. This
and diaphoret- is a life-threatening condition that requires immediate intervention to prevent
ic. Which prior- complications (eg, hypertensive stroke, seizures).
ity interventions
should the nurse Clients with a spinal cord injury should have their blood pressure checked when
perform? Select all they report a headache (Option 3). The most common cause of autonomic dysre-
that apply. flexia is bladder irritation due to distention. The client needs to be catheterized or
the possibility of a kink in the existing catheter must be assessed (Option 2). Bowel
1. Administer an impaction can also be a cause; a digital rectal examination should be performed.
analgesic as need- Constrictive clothing should be removed to decrease skin stimulation (Option 5).
ed The primary health care provider should be notified. An alpha-adrenergic blocker
2. Determine if or an arteriolar vasodilator (eg, nifedipine) may be prescribed.
there is bladder
distention (Option 1) Headaches associated with autonomic dysreflexia are typically due to
3. Measure the severe hypertension and often resolve after blood pressure has been treated.
client's blood (Option 4) The client should have the head of the bed elevated 45 degrees or
pressure high Fowler's to lower blood pressure. The Sims' position is flat and side-lying.
4. Place the client
Educational objective:Autonomic dysreflexia is a life-threatening condition in a
in the Sims' posi-
client with high spinal cord injury. Classic signs/symptoms include severe hyper-
tion
tension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerec-
5. Remove con-
tion. Emergency treatment includes correcting the cause (check bowel or bladder
strictive clothing
distention), removing tight clothing, and raising the
2. The nurse is car- 1
ing for a young Huntington disease (HD) is an incurable autosomal dominant hereditary disease
adult who is con- that causes progressive nerve degeneration, which results in impaired movement,
https://www.stuvia.com/user/actualstudy Page 1
,UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
sidering becom- swallowing, speech, and cognitive abilities. Chorea (involuntary, tic-like move-
ing pregnant. The ment) is a hallmark sign. The onset of active disease is usually at age 30-50, and
client expresses death from neuromuscular and respiratory complications typically occurs within
concern, stating, 20 years of diagnosis.
"One of my par-
ents has Hunting- HD is confirmed by genetic testing. Clients who have a parent with HD and are
ton disease, and I considering having biological children should receive genetic counseling (Option
am afraid my child 1).
will get it." How
should the nurse
Educational objective: Huntington disease is an incurable autosomal dominant
respond?
disease that causes progressive nerve degeneration, which impairs movement,
swallowing, speech, and cognitive abilities. Death typically occurs within 20 years.
1. "Genetic coun-
Clients who have a parent with this disease should receive genetic counseling,
seling is recom-
especially when planning to start a family.
mended. You will
receive a refer-
ral before you
leave."
2. "Huntington
disease inheri-
tance requires
both biological
parents to carry
the gene."
3. "There are oth-
er ways to grow
your family. You
should consider
adoption."
4. "This dis-
ease occurs spon-
taneously and is
https://www.stuvia.com/user/actualstudy Page 2
, UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
not likely to affect
your children."
3. The nurse is as- 2, 3, 4
sessing a client
with advanced Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurode-
amyotrophic lat- generative disease with no cure. ALS causes progressive degeneration of motor
eral sclerosis. neurons in the brain and spinal cord. Physical symptoms include fatigue, pro-
Which of the gressive muscle weakness, twitching and muscle spasms, difficulty swallowing,
following assess- difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients
ment findings survive only 3-5 years after the diagnosis as there is no cure.
does the nurse
Treatment focuses on symptom management. Interventions include:
expect? Select all
- Respiratory support with noninvasive positive pressure (eg, bilevel positive air-
that apply.
way pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy)
1. Diarrhea - Feeding tube for enteral nutrition
2. Difficulty - Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dys-
breathing pnea)
3. Difficulty swal- - Mobility assistive devices (eg, walker, wheelchair)
lowing - Communication assistive devices (eg, alphabet boards, specialized computers)
4. Muscle weak-
(Option 1) Constipation due to decreased mobility is more common in ALS.
ness
Diarrhea is not seen.
5. Resting tremor
(Option 5) Resting tremor is characteristic of parkinsonism.
Educational objective: Amyotrophic lateral sclerosis causes motor neuron degen-
eration that leads to progressive muscle weakness, twitching and muscle spasms,
difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure.
Treatment focuses on symptom management.
4. The nurse is 3
caring for a
client diagnosed GBS is an acute, immune-mediated polyneuropathy that is most often accom-
https://www.stuvia.com/user/actualstudy Page 3
, UWorld Neuro
UWorld Neuro
Study online at https://quizlet.com/_f98y6k
with Guillain-Bar- panied by ascending muscle weakness and absent deep-tendon reflexes. Many
ré syndrome clients have a history of antecedent respiratory tract or GI infection. Lower-ex-
(GBS) after a tremity weakness progresses over hours to days to involve the thorax, arms, and
recent gastroin- cranial nerves. However, neuromuscular respiratory failure is the most life-threat-
testinal (GI) ill- ening complication.
ness. Monitoring
for which of the Early signs indicating impending respiratory failure include:
following is a Inability to cough
nursing care pri- Shallow respirations
ority for this Dyspnea and hypoxia
client? Inability to lift the head or eye brows
1. Diaphoresis Assessing the client's pulmonary function by serial spirometry is also recommend-
with facial flush- ed. Measurement of forced vital capacity (FVC) is the gold standard for assessing
ing ventilation; a decline in FVC indicates impending respiratory arrest requiring
2. Hypoactive endotracheal intubation.
or absent bowel
(Option 1) Severe autonomic dysfunction can present as diaphoresis and facial
sounds
flushing.
3. Inability to
(Option 2) The client with GBS is also at risk for paralytic ileus, which is related to
cough or lift the
either immobility or nerve damage. As a result, the nurse should monitor for the
head
presence hypoactive/absent bowel sounds.
4. Warm, tender,
(Option 4) Clients with GBS are at risk of developing deep venous thrombosis due
and swollen leg
to lack of ambulation and should receive pharmacologic prophylaxis (heparin)
and support stockings.
Although symptoms in options 1, 2, and 4 represent a progressive illness and are
important to communicate to the health care provider promptly, they are not the
highest priority compared to impending respiratory failure.
Educational objective: Respiratory distress is a potential complication of pro-
gressing paralysis in clients with Guillain-Barré syndrome. The nurse should
https://www.stuvia.com/user/actualstudy Page 4
