Chapter 44 Test Bank + Answers Nursing Care Of Patients With - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 44 Nursing Care of Patients with Neurologic Disorders
1) The nurse is preparing to care for a patient with Alzheimer disease. What should the nurse identify as a common sign of this disorder? Select all that apply.
1. Poor or decreased judgment
2. Declining job skills
3. Inability to be comfortable in social situations
4. Obsession with organization
5. Focused on abstract thoughts
Page Ref: 1636
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
2) The nurse is reviewing medication orders for a patient with Alzheimer disease. Which medication should the nurse expect to be prescribed for this patient?
1. Rivastigmine tartrate (Exelon)
2. Adrenocorticotropic hormone (ACTH)
3. Meperidine (Demerol)
4. Acetaminophen (Tylenol)
Page Ref: 1633
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
3) The nurse is having a conversation with an older adult with Parkinson disease. What speech pattern would this patient most likely exhibit during conversation with the nurse? Select all that apply.
1. A low-pitched monotone voice
2. Bubbly, spirited discussion
3. Jumbled words that do not make sense
4. Angry, loud talk
5. Slurring and poor articulation of words
Page Ref: 1652-1653
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
4) A patient with Parkinson disease is demonstrating bradykinesia. What should the nurse expect to assess in this patient?
1. Slowed or delayed movements
2. Increased spontaneous movements
3. Active exercise and high energy
4. Very slow talk
Page Ref: 1647
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
5) The nurse notes that a patient with Parkinson disease is experiencing tremors and muscle rigidity. Which medication should the nurse expect to be prescribed for these manifestations?
1. Trihexyphenidyl (Artane)
2. Acetaminophen (Tylenol)
3. Meperidine (Demerol)
4. Nitroglycerin (Nitro-bid)
Page Ref: 1651
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
6) An adult patient with Bell palsy asks if the facial paralysis and distortion will go away. How should the nurse response to this patient?
1. "Most people recover completely within a few weeks to a few months."
2. "Everyone recovers from Bell palsy in three to five weeks."
3. "Most people have permanent facial paralysis on both sides of the face."
4. "Most people have permanent facial paralysis on one side of the face."
Page Ref: 1665
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Coping Mechanisms
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
7) A patient seeks medical attention for excruciating pain on one side of the face. What should the nurse suspect is occurring with this patient?
1. Trigeminal neuralgia
2. Parkinson disease
3. Bell palsy
4. Myasthenia gravis
Page Ref: 1664
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
8) A patient who is newly diagnosed with Huntington disease asks if this disorder can be passed on to future children. What should the nurse say in response to this patient? Select all that apply.
1. "There may be genetic concerns that should be discussed with the physician."
2. "Children will not be affected by the disease."
3. "The disease is passed on genetically in 75% of offspring."
4. "Each child will have a 50% chance of inheriting the gene."
5. "Genetic testing can determine who has the disease.
Page Ref: 1655
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
9) The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse recall is the prognosis for this patient?
1. Poor; the disease rapidly progresses and is fatal.
2. Good; the disease will progress over many years but the quality of life will be good.
3. Good; the disease progresses rapidly but can be halted by drug therapy.
4. Excellent; the disease will progress slowly and can be controlled by medication.
Page Ref: 1655
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
10) A patient is diagnosed with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the priority nursing activity for this patient?
1. Support the patient and family to meet physical and psychosocial needs.
2. Monitor for infection.
3. Assist the patient to avoid complications.
4. Assist the patient to adapt to the disease.
Page Ref: 1656
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Support Systems
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
11) A patient with Guillain-Barré syndrome asks if recovery is possible. What should the nurse respond to this patient?
1. "Recovery will be slow, but your chance of getting better is good."
2. "Only time and prayer will tell."
3. "Do not worry about that right now."
4. "Recovery is not likely."
Page Ref: 1661
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Sensory/Perceptual Alterations
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.
12) The nurse is assessing a patient with Guillain-Barré syndrome. What should the nurse expect to assess in this patient? Select all that apply.
1. Increased muscular weakness
2. Increased lower extremity edema
3. Increased confusion
4. Increased intolerance to light
5. Decreased deep tendon reflexes
Page Ref: 1661
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
13) A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis (MS). What should the nurse identify as a priority for self-care?
1. Apply for nursing positions that are less stressful and demanding.
2. Work as hard as possible now because it may not be possible later.
3. Continue to work as scheduled without making changes.
4. Leave employment as a nurse due to the need for complete bed rest.
Page Ref: 1645
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
14) The nurse is reviewing medication orders for a patient with multiple sclerosis (MS). What medication should the nurse expect to be prescribed for this patient?
1. Dexamethasone (Decadron)
2. Meperidine (Demerol)
3. Monoamine oxidase (MAO) inhibitors
4. Rivastigmine tartrate (Exelon)
Page Ref: 1643
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
15) A patient is suspected of having myasthenia gravis (MG). Which test should the nurse expect to be used to improve this patient's strength for about five minutes?
1. Tensilon test
2. Computed tomography (CT) scan of the legs
3. Nerve stimulation study
4. Analysis of anti-acetylcholine receptor antibodies
Page Ref: 1658
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
16) The nurse is assessing a patient with myasthenia gravis. Which is a characteristic of this disease? Select all that apply.
1. Routine exercise provides an improvement in muscle strength.
2. Visual problems may be an early symptom.
3. There may be difficulty swallowing.
4. Great improvement occurs in muscle strength with physical therapy.
5. There may be poor articulation in speaking.
Page Ref: 1658
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
17) A patient experiencing blurred vision and muscle spasms that occur over the past several months is scheduled for an MRI and lumbar puncture with examination of the CSF. Which important patient history information is important for the nurse to note? Select all that apply.
1. The patient is a 22-year-old woman from Canada.
2. The patient is Caucasian and lives in the United States.
3. The patient has a family history of epilepsy.
4. The patient has been depressed.
5. The patient's father had Parkinson disease.
Page Ref: 1638
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
18) A patient's spouse states, "I've noticed that my spouse doesn't sleep well anymore and sometimes can't find the right words." What is the most appropriate response by the nurse?
1. "How long have you noticed these changes?"
2. "Does anyone in your family have Alzheimer disease?"
3. "These are common changes associated with age."
4. "Do you think your spouse is depressed?"
Page Ref: 1632
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
19) The nurse visits a stage 5 Alzheimer disease patient who lives at home with a spouse. In order to meet the needs of the spouse, what should the nurse suggest?
1. Finding respite care to come into the home several days a week
2. Making arrangements for the patient to visit the local senior citizens' center in the afternoon
3. Providing the patient a list of daily activities to complete
4. Finding placement in a long-term care facility
Page Ref: 1632, 1636
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity: Support Systems
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
20) A patient complains of periods of confusion and forgetfulness at times, and reports clear thought process at most times of the day. The symptoms have been gradually worsening. What should the nurse say in response to this patient?
1. "Have you started any new medications since the symptoms began?"
2. "You probably have nothing to worry about; it's most likely stress-related."
3. "Everybody has a few problems with memory as they get older."
4. "You should probably have an MRI of your brain."
Page Ref: 1632
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
21) A patient with Parkinson disease asks the nurse what an "on-off" problem means with medications. What should the nurse explain to the patient?
1. "The 'on' times will be when your symptoms are under control; the 'off' times are when you will have increased problems with symptom management."
2. "There will be times when you are depressed (off) and when you are happy (on)."
3. "You will have to take breaks from this medicine by stopping (off) and starting it (on) again, so you don't build up a tolerance to it."
4. "I'm not a pharmacist, so I shouldn't be answering this question."
Page Ref: 1650
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
22) A patient with myasthenia gravis is prescribed pyridostigmine (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report? Select all that apply.
1. Increased weakness
2. Problems with increased drooling
3. Orthostatic hypotension
4. Headache
5. Increased difficulty swallowing
Page Ref: 1659
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
23) A patient with stage 2 Alzheimer disease becomes very agitated in the evenings. What would be an appropriate intervention for the nurse to use for this patient?
1. Playing soft music in the patient's room
2. Using anti-anxiety medications or tranquilizers
3. Moving the patient to an area of activity to provide distraction
4. Recommending the patient be moved to a more secure environment
Page Ref: 1632, 1633
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
24) The spouse of a patient with Alzheimer disease (AD) asks what sundowning means. How should the nurse respond to this question?
1. "It causes agitation, disorientation to time, and wandering during the afternoon or early evening."
2. "The eyes will appear more downcast and the lids will droop."
3. "Repetition of words or phrases occurs more frequently."
4. "The ability to perform simple tasks is lost."
Page Ref: 1635
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.
25) The nurse is completing discharge teaching to a patient with a new diagnosis of multiple sclerosis (MS). What does the nurse recommend about diet?
1. Focus on maintaining a weight as close as possible to what is recommended for the patient's height and weight.
2. Increase fats and lower carbohydrates.
3. Include foods that are easy to swallow since dysphagia is a problem seen in the early stages of the disease.
4. Basically remain the same, as there are no nutritional changes in the MS patient.
Page Ref: 1643
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
26) The nurse suspects that a patient has Parkinson disease (PD). What did the nurse assess as early signs of this neurologic disease? Select all that apply.
1. Fatigue
2. Cogwheel rigidity
3. Being "frozen"
4. Bilateral involvement
5. A slight rhythmic hand tremor
Page Ref: 1647
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
27) The nurse is completing teaching to a patient with a new diagnosis of Bell palsy. What should be a priority focus of this teaching?
1. Eye care
2. Promoting effective swallowing
3. Pain management
4. Improving muscle strength in the upper extremity
Page Ref: 1666
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.
28) The nurse is caring for a patient with trigeminal neuralgia. What should the nurse expect the treatment focus to be for this health problem?
1. Drugs such as tricyclic anticonvulsants or rhizotomy
2. Antiviral drugs such as acyclovir and physical therapy
3. Respiratory support and NSAIDs
4. Physical therapy and warm, moist packs to the affected area
Page Ref: 1664
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
29) 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?
1. Respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication
2. Providing gastrostomy feedings as soon as possible so as to build up muscle mass when motor functions return
3. Pain management and active range-of-motion (ROM) exercises
4. Giving immunosuppressants
Page Ref: 1656
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.
30) The nurse is caring for a patient with Guillain-Barré syndrome. Which medication should the nurse expect to provide to this patient? Select all that apply.
1. Antibiotics for urinary tract or respiratory infections
2. Morphine for muscle pain
3. Anticoagulants to prevent DVTs and pulmonary emboli
4. Anticonvulsants to prevent seizures
5. Anticholinesterase inhibitors to improve muscle strength
Page Ref: 1661
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.
31) 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? Select all that apply.
1. Foot drop
2. Slurred speech
3. Weak hip flexor muscles
4. Bilateral weak hand grasps
5. Fine muscle fasciculations of the hands
Page Ref: 1655
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.
Document Information
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By LeMone, Burke, Gerene Bauldoff
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Chapter 42 Nursing Care Of Patients With Intracranial Disorders
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Chapter 43 Spine & CNS Disorder Care
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Chapter 44 Nursing Care Of Patients With Neurologic Disorders
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Chapter 45 Assessing The Eye And Ear
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Chapter 46 Nursing Care Of Patients With Eye And Ear Disorders
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