NSG 330 Ch 69- Management Neurologic Infections,
Autoimmune Disorders, Neuropathies Questions With
Complete Solutions
A client is experiencing muscle weakness and an ataxic gait.
The client has a diagnosis of multiple sclerosis (MS). Based on
these symptoms, the nurse formulates "Impaired physical
mobility" as one of the nursing diagnoses applicable to the
client. What nursing intervention should be most appropriate to
address the nursing diagnosis?
Help the client perform range-of-motion (ROM) exercises every
8 hours.
Explanation:
Helping the client perform ROM exercises every 8 hours helps
in promoting joint flexibility and muscle tone in a client with
muscle weakness. Measures such as using pressure-relieving
devices or changing the body positions every 2 hours prevents
skin breakdown. The nurse should use a footboard and
trochanter rolls to promote a neutral body position that will keep
the body in good alignment.
The nurse is evaluating the progression of a client in the home
setting. Which activity of the hemiplegic client best indicates
that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
Explanation:
,The best evidence that the client is assuming independence is
providing range of motions exercises to the affected arm by
grasping the arm at the wrist and raising it. The other options
require assistance.
The nurse is assisting with administering a Tensilon test to a
patient with ptosis. If the test is positive for myasthenia gravis,
what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and
ptosis will be relieved for approximately 5 minutes.
Explanation:
Thirty seconds after injection, facial muscle weakness and ptosis
should resolve for about 5 minutes (Hickey, 2009). Immediate
improvement in muscle strength after administration of this
agent represents a positive test and usually confirms the
diagnosis.
A nurse is assisting with a neurological examination of a client
who reports a headache in the occipital area and shows signs of
ataxia and nystagmus. Which of the following conditions is the
most likely reason for the client's problems?
Cerebellar abscess
Explanation:
Indicators of a cerebellar abscess include occipital headache,
ataxia, and nystagmus.
Which client goal, established by the nurse, is most important as
the nurse plans care for a seizure client in the home setting?
,The client will remain free of injury if a seizure does occur.
Explanation:
All of the goals are appropriate, but the most important goal is
the long-term goal to remain free of injury if a seizure occurs.
Nursing interventions associated can include notifying someone
of not feeling well, lowering self to a safe position, protecting
head, turning on a side, etc. Also, the client may be at a risk for
injury because, once a seizure begins, the client cannot
implement self-protective behaviors. An established plan is
important in the care of a seizure client. The other options are
acceptable goals for nursing care.
The nurse is planning care of a client admitted to the neurologic
rehabilitation unit following a cerebrovascular accident. Which
nursing intervention would be of highest priority?
Include client in planning of care and setting of goals.
Explanation:
The client in a rehabilitation setting has moved to the recovery
phase. The highest priority is to include the client in the
rehabilitation plan. Tailoring the rehabilitation plan to meet the
needs of the client can promote optimal participation by the
client in the rehabilitative process. The other options are
appropriate in certain situations but not the highest priority.
The nurse is caring for a client with Bell's palsy. Which of the
following teaching points is a priority in the management of
symptoms for this client?
Use ophthalmic lubricant and protect the eye.
, Explanation:
The VII cranial nerve supplies muscles to the face. In Bell's
palsy, the eye can be affected which results in incomplete
closure and risk for injury. The eye can become dry and irritated
unless eye moisturizing drops and ophthalmic ointment is
applied. Avoiding stimuli that can trigger pain is specific to tic
douloureux (cranial nerve V disorder). Encouraging dental
exams is a part of care but not the priority. Antibiotics are not
used in the treatment of Bell's palsy because it is thought to be
caused by a virus.
The nurse is caring for a patient with MS who is having
spasticity in the lower extremities that decreases physical
mobility. What interventions can the nurse provide to assist with
relieving the spasms? Select all that apply.
Demonstrate daily muscle stretching exercises.
Apply warm compresses to the affected areas.
Allow the patient adequate time to perform exercises
Explanation:
Warm packs may be beneficial for relieving spasms, but hot
baths should be avoided because of risk of burn injury secondary
to sensory loss and increasing symptoms that may occur with
elevation of the body temperature. Daily exercises for muscle
stretching are prescribed to minimize joint contractures. The
patient should not be hurried in any of these activities, because
this often increases spasticity.
Autoimmune Disorders, Neuropathies Questions With
Complete Solutions
A client is experiencing muscle weakness and an ataxic gait.
The client has a diagnosis of multiple sclerosis (MS). Based on
these symptoms, the nurse formulates "Impaired physical
mobility" as one of the nursing diagnoses applicable to the
client. What nursing intervention should be most appropriate to
address the nursing diagnosis?
Help the client perform range-of-motion (ROM) exercises every
8 hours.
Explanation:
Helping the client perform ROM exercises every 8 hours helps
in promoting joint flexibility and muscle tone in a client with
muscle weakness. Measures such as using pressure-relieving
devices or changing the body positions every 2 hours prevents
skin breakdown. The nurse should use a footboard and
trochanter rolls to promote a neutral body position that will keep
the body in good alignment.
The nurse is evaluating the progression of a client in the home
setting. Which activity of the hemiplegic client best indicates
that the client is assuming independence?
The client grasps the affected arm at the wrist and raises it.
Explanation:
,The best evidence that the client is assuming independence is
providing range of motions exercises to the affected arm by
grasping the arm at the wrist and raising it. The other options
require assistance.
The nurse is assisting with administering a Tensilon test to a
patient with ptosis. If the test is positive for myasthenia gravis,
what outcome does the nurse know will occur?
Thirty seconds after administration, the facial weakness and
ptosis will be relieved for approximately 5 minutes.
Explanation:
Thirty seconds after injection, facial muscle weakness and ptosis
should resolve for about 5 minutes (Hickey, 2009). Immediate
improvement in muscle strength after administration of this
agent represents a positive test and usually confirms the
diagnosis.
A nurse is assisting with a neurological examination of a client
who reports a headache in the occipital area and shows signs of
ataxia and nystagmus. Which of the following conditions is the
most likely reason for the client's problems?
Cerebellar abscess
Explanation:
Indicators of a cerebellar abscess include occipital headache,
ataxia, and nystagmus.
Which client goal, established by the nurse, is most important as
the nurse plans care for a seizure client in the home setting?
,The client will remain free of injury if a seizure does occur.
Explanation:
All of the goals are appropriate, but the most important goal is
the long-term goal to remain free of injury if a seizure occurs.
Nursing interventions associated can include notifying someone
of not feeling well, lowering self to a safe position, protecting
head, turning on a side, etc. Also, the client may be at a risk for
injury because, once a seizure begins, the client cannot
implement self-protective behaviors. An established plan is
important in the care of a seizure client. The other options are
acceptable goals for nursing care.
The nurse is planning care of a client admitted to the neurologic
rehabilitation unit following a cerebrovascular accident. Which
nursing intervention would be of highest priority?
Include client in planning of care and setting of goals.
Explanation:
The client in a rehabilitation setting has moved to the recovery
phase. The highest priority is to include the client in the
rehabilitation plan. Tailoring the rehabilitation plan to meet the
needs of the client can promote optimal participation by the
client in the rehabilitative process. The other options are
appropriate in certain situations but not the highest priority.
The nurse is caring for a client with Bell's palsy. Which of the
following teaching points is a priority in the management of
symptoms for this client?
Use ophthalmic lubricant and protect the eye.
, Explanation:
The VII cranial nerve supplies muscles to the face. In Bell's
palsy, the eye can be affected which results in incomplete
closure and risk for injury. The eye can become dry and irritated
unless eye moisturizing drops and ophthalmic ointment is
applied. Avoiding stimuli that can trigger pain is specific to tic
douloureux (cranial nerve V disorder). Encouraging dental
exams is a part of care but not the priority. Antibiotics are not
used in the treatment of Bell's palsy because it is thought to be
caused by a virus.
The nurse is caring for a patient with MS who is having
spasticity in the lower extremities that decreases physical
mobility. What interventions can the nurse provide to assist with
relieving the spasms? Select all that apply.
Demonstrate daily muscle stretching exercises.
Apply warm compresses to the affected areas.
Allow the patient adequate time to perform exercises
Explanation:
Warm packs may be beneficial for relieving spasms, but hot
baths should be avoided because of risk of burn injury secondary
to sensory loss and increasing symptoms that may occur with
elevation of the body temperature. Daily exercises for muscle
stretching are prescribed to minimize joint contractures. The
patient should not be hurried in any of these activities, because
this often increases spasticity.
