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Chapter 56: Nursing Assessment: Nervous System
A patient with a deep, large laceration of the left forearm, which has damaged nerve fibers as well as other tissue, asks the nurse to explain what the effect of the nerve damage will be. The nurse should respond that
In the peripheral nerve system (PNS), regeneration of injured nerve fibers is possible if the cell body is intact. The final result depends on the connections the axon sprouts make with end-organs and other nerves. Nerves of the central nervous system (CNS) do not regenerate, but peripheral nerves have some regenerative abilities. Return of normal or weak function is possible, but the nurse should not imply that either is guaranteed.
When interviewing an acutely confused patient with a head injury, which of these questions will provide the most useful information?
The acutely confused patient will be able to state whether there is pain currently. The patient may not be able to provide accurate information about history of hospitalization, 24-hour dietary recall, or usual coping patterns.
When the nurse administers gabapentin (Neurontin), a drug that increases the level of gamma-aminobutyric acid (GABA) in the synapse, the effect the nurse would expect is
GABA is a neurotransmitter that has inhibitory activity on action-potential generation and decreases nervous system activity. Because it has an inhibitory effect, the nurse will not expect increases in nervous system activity, increased alertness or arousal, or excitation of affected neurons.
In a patient who has a corticospinal tract lesion, the nurse should assess for
A patient has a lesion that affects lower motor neurons. During assessment of the patient’s lower extremities, the nurse expects to find
Because the cell bodies of lower motor neurons are located in the spinal cord, damage to the neuron will decrease motor activity of the affected muscles. Spasticity and hyperactive reflexes are caused by upper motor neuron damage. Sensation is not impacted by motor neuron lesions.
Propranolol (Inderal), an adrenergic blocking agent that inhibits sympathetic nervous system activity, is prescribed for a patient. The nurse monitors the patient for
Inhibition of the fight or flight response leads to decreased heart rate. Dry mouth, constipation, and urinary retention are associated with PNS blockade.
When obtaining a health history from a patient with a neurologic problem, which question by the nurse will elicit the most useful response from the patient?
The most useful and valid information is obtained through the use of open-ended questions that allow the patient to describe symptoms. The other questions encourage the use of “yes” or “no” responses and may cause the patient to omit useful additional data.
When admitting a patient with acute confusion to the hospital, the nurse will interview the patient about health problems and health history primarily to
Appropriateness of the patient’s response and the patient’s use of language will help the nurse to assess the baseline cognitive abilities of the patient. A confused patient may not be able to participate in self-care or make informed health care decisions. The health history given by a confused patient should not be used to guide decisions about care unless it can be verified by another source.
When a 71-year-old patient who is being admitted to the hospital for minor surgery tells the nurse, “I haven’t slept through the night for several years now,” the nurse will plan to
Normal changes in the reticular activating system and autonomic nervous system lead to more spontaneous awakening and less sleep time in older adults. For these normal changes, there is no indication for sedative use, EEG testing, or cranial nerve testing.
The optic nerve is responsible for visual fields and visual acuity. Trigeminal and facial nerve functions are tested by assessing the corneal reflex. Assessment of pupil response to light and ptosis are used to check function of the oculomotor nerve.
Neurologic testing of the patient by the nurse indicates impaired functioning of the left glossopharyngeal nerve (CN IX) and the vagus nerve (CN X). Based on these findings, the nurse plans to
: The glossopharyngeal and vagus nerves innervate the pharynx and control the gag reflex; a patient with impaired function of these nerves is at risk for aspiration. An oral airway may be needed when a patient is unconscious and unable to maintain the airway, but it will not decrease aspiration risk. Taste and eye blink are controlled by the facial nerve.
The following orders are received for a patient who is unconscious after a head injury caused by an automobile accident. Which one should the nurse question?
After a head injury, the patient may be experiencing intracranial bleeding and increased intracranial pressure, which could lead to herniation of the brain with lumbar puncture. The other orders are appropriate.
The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal cord lesion for sensation. Which action indicates a need for further teaching about neurologic assessment?
When performing a sensory assessment, the nurse should not provide verbal clues. The other actions by the new nurse are appropriate.
A patient is scheduled for a lumbar puncture. The nurse will plan to
For a lumbar puncture, the patient lies in the lateral recumbent position, with the knees drawn to the chest and the head flexed to the chest to separate the vertebrae. The procedure does not usually require a sedative, is done in the patient room, and has no risk for aspiration.
When reviewing the results of a patient’s cerebrospinal fluid analysis, the nurse will notify the health care provider about
The glucose level is low. The pH, WBCs, and protein values are normal.
A patient is scheduled for a myelogram to confirm the presence of a herniated intervertebral disk. Which information obtained when admitting the patient is most important for the nurse to communicate to the health care provider before the procedure?
Iodine containing contrast medium is injected into the subarachnoid space during a myelogram. The health care provider may need to modify the post-myelogram orders to prevent back pain, but this can be done after the procedure. Clear liquids are usually considered safe up to 4 hours before a diagnostic or surgical procedure. The patient’s anxiety should be addressed, but this is not as important as the iodine allergy.
During the neurologic assessment, the patient cooperates with the nurse’s directions to grip with the hands and to move the feet but does not respond to the nurse’s questions. The nurse will suspect
A patient with a brainstem infarction is admitted to the nursing unit. The priority nursing assessment for the patient is
When developing a plan of care for a patient with dysfunction of the cerebellum, the nurse will include interventions to
Because functions of the cerebellum include coordination and balance, the patient with dysfunction is at risk for falls. The cerebellum does not impact on memory, mood, or swallowing ability.
Chapter 57: Nursing Management: Acute Intracranial Problems
A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg. The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates
The patient’s CPP is 56, below the normal of 70 to 100 mm Hg and approaching the level of ischemia and neuronal death. The patient has low cerebral blood flow/perfusion. Normal ICP is 0 to 15 mm Hg.
The patient’s cerebral perfusion pressure is only 46 mm Hg, which will rapidly lead to cerebral ischemia and neuronal death unless rapid action is taken to reduce ICP and increase arterial BP. Documentation and monitoring are inadequate responses to the patient’s problem. Elevating the head of the bed will lower the ICP but may also lower cerebral blood flow and further decrease CPP. Changes in pupil response to light are signs of increased ICP, so the nurse will only take more time doing this without adding any useful information.
Which of these patients is most appropriate for the intensive care unit (ICU) charge nurse to assign to an RN who has floated from the medical unit?
: An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The post-craniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.
A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L), a decreasing level of consciousness (LOC) and complains of a headache. All of the following orders have been received. Which one should the nurse accomplish first?
The patient’s low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse’s first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased ICP. Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
Family members are optimistic about a comatose patient’s recovery because the patient’s eyes open and the patient appears to be awake at times. Which statement by the nurse to the family is appropriate?
Arousal is controlled by the reticular activating system in the brainstem and will allow the patient to maintain wakefulness even though the damage to the cerebral cortex is severe. The patient’s behavior is not a reflex action. The behaviors of eye opening and wakefulness are not indicators of improvement in the comatose condition.
When assessing a patient with a head injury, the nurse recognizes that the earliest indication of increased intracranial pressure (ICP) is
LOC is the most sensitive indicator of the patient’s neurologic status and possible changes in ICP. Vomiting and sluggish pupil response to light are later signs of increased ICP. A headache can be caused by compression of intracranial structures as the brain swells, but it is not unexpected after a head injury.
A patient admitted with a head injury has admission vital signs of temperature 98.6° F (37° C), blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the ICP has increased and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
When caring for a patient with a right-sided intracerebral hemorrhage, the nurse suspects possible supratentorial herniation and compression of the brainstem when the
A dilated pupil on the ipsilateral side in a patient with an acute brain injury indicates herniation. Absent corneal reflexes and nystagmus are not symptoms of herniation. A nonreactive left pupil would be consistent with left-sided damage.
When the nurse applies a painful stimulus to the nailbeds of an unconscious patient, the patient responds with internal rotation, adduction, and flexion of the arms. The nurse documents this as
Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is general, it does not indicate localization of pain or flexion withdrawal.
When a patient’s intracranial pressure (ICP) is being monitored with an intraventricular catheter, which of these data obtained during the assessment is most important to communicate to the health care provider?
Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters; the temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time.
The charge nurse observes an inexperienced staff nurse who is caring for a patient who has had a craniotomy for a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the spouse. In admitting the patient, the nurse will first assess
Airway patency and breathing are the most vital functions and should be assessed first. The neurologic assessments should be accomplished next and the health and medication history last.
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with a head injury. To evaluate the effectiveness of the therapy, the nurse should
The purpose of hyperventilation for a patient with a head injury is reduction of ICP, and ICP should be monitored to evaluate whether the therapy is effective. Although oxygen saturation and ABGs are monitored in patient’s receiving hyperventilation, they do not provide data about whether the therapy is successful in reducing ICP. Breath sounds are assessed, but they are not helpful in determining whether the hyperventilation is effective.
The health care provider prescribes IV mannitol (Osmitrol) for an unconscious patient. The nurse will determine that the medication is effective if
Mannitol is an osmotic diuretic and will reduce cerebral edema and ICP. It will not directly affect seizure activity or abnormal EEG activity. A decreased GCS would indicate worsening of the patient’s neurologic status.
A patient with a severe head injury has been maintained on IV fluids of 5% dextrose in water (D5W) at 50 ml/hr for 3 days. The nurse will anticipate the need to
The patient is in a hypermetabolic and hypercatabolic state, and enteral feedings will provide nutrients for brain function and also for healing and immune function. 5% dextrose does not provide adequate nutrition to meet patient needs and can lead to lower serum osmolarity and cerebral edema. A total fluid intake of 1200 ml for 24 hours will not cause cerebral edema. Albumin administration will temporarily increase serum protein, but the patient also requires lipids, carbohydrate, and other nutrients that will be supplied through enteral feeding.
When caring for a patient who has had a head injury, which assessment information is of most concern to the nurse?
The change in level of consciousness (LOC) is an indicator of increased ICP and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual.
The nurse identifies a nursing diagnosis of ineffective breathing pattern related to loss of central nervous system (CNS) integrative function for a patient who has posttraumatic brain swelling, based on the finding of
Apneustic breathing is caused by loss of CNS integration in the pons and is not effective in maximizing gas exchange. Crackles on inspiration are abnormal, but they are not an indication of an abnormal breathing pattern. The Glasgow Coma Scale and cerebral perfusion pressure P are not useful in determining or documenting a patient’s respiratory patterns.
A patient is admitted unconscious to the emergency department (ED) after falling and hitting the head on a rock while hiking. The patient’s spouse and children stay at the patient’s side and constantly ask about the treatment being given. The nurse’s best approach to the patient’s family is to
The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.
An unconscious patient has a nursing diagnosis of ineffective tissue perfusion (cerebral) related to cerebral tissue swelling. An appropriate nursing intervention for this problem is to
The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.
The nurse notes that a patient with a head injury has a clear nasal drainage. The most appropriate nursing action for this finding is to
If the drainage is cerebrospinal fluid (CSF) leakage from a dural tear, glucose will be present. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. A dural tear does increase the risk for infections such as meningitis, but the nurse should first determine whether the clear drainage is CSF. Blowing the nose is avoided to prevent CSF leakage.
A patient is brought to the emergency department (ED) after being hit in the head with a baseball during a company picnic. On admission, the patient has a headache and cannot remember being hit but has no other signs of neurologic deficit. The nurse will plan to
A patient with a minor head trauma is usually discharged with instructions about neurologic monitoring and the need to return if neurologic status deteriorates. MRI, hospital admission, and continued observation in the ED are not indicated in a patient who only briefly lost consciousness and has no neurologic deficits.
A victim of an automobile accident was found unconscious at the scene of the accident but briefly regained consciousness during transport to the hospital. On admission, the Glasgow Coma Scale score is 8, and an acute epidural hematoma is suspected. The nurse will anticipate the need to
The principal treatment for epidural hematoma is rapid surgery to remove the hematoma and prevent herniation. If ICP is elevated after surgery, furosemide or high-dose barbiturate therapy may be needed, but these will not be of benefit unless the hematoma is removed. Minimal blood loss occurs with head injuries, and transfusion is usually not necessary.
While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient’s nose. Which of these admission orders should the nurse question?
Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevation of the head, and cold pack applications are appropriate orders.
In planning discharge for the patient following brain trauma, the nurse includes teaching and support for the family, primarily because
Changes in personality, concentration, and memory are common after severe head injury and require anticipatory guidance for the patient and family. Recovery continues for up to 6 months after the injury. Most families are able to cope with the changes in role during the convalescence. Seizure disorders are more common soon after brain injury, and most patients do not develop seizures.
When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find
The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem.
A patient with increasing headaches who is having diagnostic testing for a brain tumor asks the nurse what type of treatment will be used if a tumor is discovered. Which response by the nurse is most appropriate?
Treatment is designed to reduce tumor size or remove the tumor. Benign brain tumors place pressure on intracranial structures and need to be treated. Surgery is the preferred initial therapy but may not be possible for tumors located deep in the brain. The usefulness of chemotherapy is limited in brain tumors; chemotherapy is usually not the initial treatment.
Four days after a patient has undergone a craniotomy to remove an astrocytoma of the temporal lobe, the dressing is removed and the nurse finds the patient crying. The patient tells the nurse, “I look awful and feel even worse.” The most appropriate nursing diagnosis for the patient is
The patient’s statement about looking and feeling awful supports the diagnosis of disturbed body image, which is common after surgery because of shaving of the scalp, incisions, and dressings, etc. There is no indication that the patient’s immediate concern is with dying. The patient does not have indications of denial. The assessment data do not indicate that the patient feels hopeless or that cerebral edema is contributing to the patient’s emotional status.
A patient with a brain tumor is receiving radiation after having had a craniotomy. The nurse will explain that the purpose of the ordered methylprednisolone (Solu-Medrol) is to
Radiation can lead to cerebral edema and rapid ICP increases and corticosteroids are administered to prevent this. Corticosteroids do not damage tumor cells, promote wound healing, or decrease risk for metastasis.
Following a craniotomy with a craniectomy and left anterior fossae incision, the patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness (LOC) and weakness. An appropriate nursing intervention is to
ROM exercises will help to prevent the complications of immobility. Patients with anterior craniotomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.
A patient who has bacterial meningitis and is disoriented and anxious has a nursing diagnosis of disturbed sensory perception related to decreased level of consciousness. An appropriate nursing intervention is to
: Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.
When assessing a patient with bacterial meningitis, the nurse obtains all of the following information. Which should be reported immediately to the health care provider?
Shock is a serious complication of meningitis, and the patient’s low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig’s sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.
A patient admitted with bacterial meningitis and a temperature of 102° F has orders for all of these collaborative interventions. Which one should the nurse accomplish first?
Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Administration of dexamethasone and initiation of hypothermia therapy should be done as quickly as possible once cultures and antibiotics are initiated.
The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important?
The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvaccinated teens entering high school, and college freshmen. Hand washing may help to decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN?
Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.
Chapter 58: Nursing Management: Stroke
The nurse obtains all of the following information about a 65-year-old patient in the clinic. When developing a plan to decrease stroke risk, which risk factor is most important for the nurse to address?
: Hypertension is the most important modifiable risk factor. Smoking, physical inactivity, and obesity all contribute to stroke risk but not so much as hypertension.
A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered. Which order should the nurse act on first?
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the smaller the area of brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
The patient’s symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient’s symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, but not for TIA.
A sudden-onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When obtaining admission assessment data about the patient’s clinical manifestations, it is most important the nurse assess the patient’s
: Because the patient with a left-sided brain stroke may also have difficulty with comprehension and use of language, so it is important to obtain baseline data about the ability to follow commands. This will impact on patient safety and nursing care. The visual fields are not typically affected by a left-sided stroke. Information about reflexes and emotional state will be collected but is not as high a priority as information about language abilities.
The nurse on the medical unit receives a verbal report from the emergency department nurse that a patient has an occlusion of the left posterior cerebral artery. When admitting the patient to the medical floor, the nurse will anticipate that the patient may have
Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
The health care provider prescribes clopidogrel (Plavix) for a patient with cerebral atherosclerosis. When teaching about the new medication, the nurse will tell the patient
Plavix inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
The health care provider recommends a carotid endarterectomy for a patient with carotid atherosclerosis and a history of transient ischemic attacks (TIA). The patient asks the nurse to describe the procedure. Which response by the nurse is appropriate?
: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, “The diseased portion of the artery in the brain is removed” describes an arterial graft procedure. The answer beginning, “A catheter with a deflated balloon is positioned at the narrow area” describes an angioplasty. The final response (beginning, “A wire is threaded through the artery”) describes the Merci procedure.
On initial assessment of a patient hospitalized following a stroke, the nurse finds the patient’s blood pressure to be 180/90 mm Hg. Which of the following orders by the health care provider should the nurse question?
Since elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if MAP is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 ml daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A patient with a history of several transient ischemic attacks (TIAs) arrives in the emergency room with hemiparesis and dysarthria that started 2 hours previously. The nurse anticipates the need to prepare the patient for
The patient’s history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 3 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy are not indicated for the patient who is having an acute ischemic stroke.
The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient communicate is to
Communication will be facilitated and less frustrating to the patient when questions that require a “yes” or “no” response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The priority nursing diagnosis for the patient is
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
A patient has a stroke affecting the right hemisphere of the brain. Based on knowledge of the effects of right brain damage, the nurse establishes a nursing diagnosis of
Right-sided brain damage typically causes denial of any deficits and poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
A patient with homonymous hemianopsia resulting from a stroke has a nursing diagnosis of disturbed sensory perception related to hemianopsia. To help the patient learn to compensate for the deficit during the rehabilitation period, the nurse should
: During the rehabilitation period, placing objects on the affected side will encourage the patient to use the scanning technique to visualize the affected side. Because homonymous hemianopsia affects half the visual field in each eye, use of an eye patch is not appropriate. Approaching the patient on the affected side is appropriate during the acute period but does not help the patient learn skills needed to compensate for the visual defect. The problem is with the visual field, not with the eye muscles, so practice moving the eyes through the visual field will not be effective.
A patient who has had a subarachnoid hemorrhage is being cared for in the intensive care unit. Which information about the patient is most important to communicate to the health care provider?
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a high level after a subarachnoid hemorrhage. A low or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self for a patient with right-sided hemiplegia. An appropriate nursing intervention is to
Because the nursing diagnosis indicates that the patient’s imbalanced nutrition is related to the right-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the left hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
The nurse is assisting the patient who is recovering from an acute stroke and has right-side hemiplegia to transfer from the bed to the wheelchair. Which action by the nurse is appropriate?
Placing the wheelchair on the patient’s left side will allow the patient to use the left hand to grasp the left arm of the chair to transfer. If the chair is placed on the patient’s right side or in front of the patient, it will be awkward to use the strong arm, and the patient will be at increased risk for a fall. Because the patient has hemiplegia, it is not appropriate to place the chair where the patient will need to walk to it.
A 32-year-old patient has a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for deep vein thrombosis (DVT). Activities (such as coughing and sitting up) that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A patient who has had a stroke has a new order to attempt oral feedings. The nurse should assess the gag reflex and then
The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
A patient has right-sided weakness and aphasia as a result of a stroke but is attempting to use the left hand for feeding and other activities. The patient’s wife insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” A nursing diagnosis that is most appropriate in this situation is
The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. The patient’s attempts to use the left hand indicate that he is managing the therapeutic regimen appropriately.
Several weeks after a stroke, a patient has urinary incontinence resulting from an impaired awareness of bladder fullness. A bladder retraining program for the patient should include
Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1000-ml fluid intake is too restricted and will lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
A 72-year-old is being discharged home following a stroke. The patient is able to walk with assistance but needs help with hygiene, dressing, and eating. Which statement by the patient’s wife indicates that discharge planning goals have been met?
: The statement that community resources will be used indicates a realistic outcome. The patient is unlikely to continue to improve to the point of needing no assistance. The wife is likely to be overwhelmed by the patient’s needs if she attempts to manage without assistance. There is no indication that the patient will need a home health aide to meet all of his care needs.
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering the medications, the patient says, “I don’t need the aspirin today. I don’t have any aches or pains.” Which action should the nurse take?
: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
A patient is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the patient about
Following a TIA, patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
The nurse is caring for a patient with carotid artery narrowing who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual as a result of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure; the nurse should have the patient take some deep breaths.
A patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
The initial nursing action should be to assess the airway and take any needed actions to assure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, circulation) are completed.
A patient with sudden-onset right-sided weakness has a CT scan and is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
The use of warfarin will have contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient’s control and asking the patient to stop will lead to embarrassment.
Chapter 59: Nursing Management: Chronic Neurologic Problems
A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of the following medications ordered on a PRN basis for the patient should the nurse administer initially?
The patient’s symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and Fiorinal would be more appropriate for a headache that did not respond to a nonopioid analgesic.
A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. The patient says, “I am afraid to make social plans because I never know when I will have these headaches.” The most appropriate nursing action at this time is to
: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed.
After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says,
It is recommended that the patient with a migraine rest in a dark, quiet area. Topamax is used to prevent migraines and must be taken for several months to determine effectiveness. Blood flow to the brain is decreased by the triptan drugs. Alcohol may precipitate migraine headaches.
When a patient is being evaluated for new onset cluster-type headaches, the nurse will anticipate
Diagnosis of cluster headache is made primarily on the basis of the patient’s symptoms. Other diagnostic tests are only obtained if an underlying disorder is suspected as the cause of the headache.
A patient experiences cluster headaches that occur for 2 months every year. During assessment of the patient who is experiencing a headache episode, the nurse would expect to find
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none is an indication that sumatriptan would be an inappropriate treatment.
A patient has a tonic-clonic seizure while the nurse is in the patient’s room. During the seizure, it is important for the nurse to
Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to
The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.
After experiencing a generalized tonic-clonic seizure in the classroom, an elementary school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries and tells the nurse, “I can not teach anymore. It will be too difficult for the students if this happens again at work.” The most appropriate nursing diagnosis for the patient is
The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication. Because the focus of the patient’s statement is on career issues, this is a more appropriate diagnosis than anxiety, hopelessness, or disturbed body issues.
The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin, which patient statement indicates understanding of the medication?
Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved. Gingival hyperplasia associated with phenytoin use can be decreased by frequent brushing and flossing. Most seizures do not require hospitalization. The phenytoin is taken regularly to prevent seizures, not acutely when seizures occur.
When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?
To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Although the capillary blood glucose may offer information about the cause of the seizure, the initial nursing action is to decrease the risk for further seizures. Monitoring level of consciousness is important, but the highest priority is to decrease seizure risk.
A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates a(n) _____ seizure.
The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. In addition, an alteration in consciousness is always manifested. Symptoms of an absence seizure are staring and a brief loss of consciousness. During a simple partial seizure, the patient does not lose consciousness. A generalized myoclonic seizure is characterized by a sudden jerk of the body or extremities.
When teaching the patient with newly diagnosed multiple sclerosis (MS) about the disease, the nurse explains that
: The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission. Although MS susceptibility does appear to be inherited, the disease is not congenital because the interaction of multiple factors precipitates MS development. Impulse transmission along nerve fibers is slowed. Antibodies to acetylcholine receptors do not cause MS.
When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should
: Extremity weakness or spasms are common motor symptoms of MS. Memory deficit and confusion are not symptoms of MS, and the patient will be an accurate historian. Although viral infection appears to trigger the onset of MS in some patients, temperature spikes are not associated with viral illness. Decreased libido and diminished sexual response are common MS symptoms.
A 28-year-old woman has had multiple sclerosis (MS) for 3 years and wants to have children before her disease worsens. When she asks about the risks associated with pregnancy, the nurse explains that
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Pregnancy, labor, and delivery are not affected by MS.
A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). In planning the patient teaching necessary with the use of the drug, the nurse recognizes that the patient will need to be taught
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. No laboratory monitoring is needed. The purpose of the medication is to modify the MS disease process.
When planning care for a patient with MS who has a nursing diagnosis of risk for activity intolerance related to extremity weakness secondary to stress, the most appropriate patient goal is
Because the nurse has identified the patient’s problem as activity intolerance, a patient goal that indicates improvement in activity tolerance, such as ability to accomplish ADLs without fatigue, is most appropriate. The other goals are appropriate for nursing diagnoses such as ineffective coping, impaired physical mobility, and inadequate nutritional intake.
A patient with multiple sclerosis (MS) has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to
The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson’s disease. To assist the patient to ambulate safely, the nurse should
Rocking the body from side to side stimulates balance and improves mobility. The patient should initially be ambulated with assistance but might not require continual assistance with ambulation. The patient should maintain a wide base of support to help with balance. The patient should lift the feet and avoid a shuffling gait.
A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson’s disease is experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from
After the dopamine receptor agonists begin to fail to relieve symptoms, the addition of L-dopa with carbidopa can be added to the regimen. Complete drug withdrawal will result in worsening of symptoms. Anticholinergic therapy should be continued to help maintain the balance between the actions of dopamine and acetylcholine. Increasing the dose of bromocriptine will increase the risk for toxic effects.
A patient with Parkinson’s disease has decreased tongue mobility and an inability to move the facial muscles. The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of
The inability to use the tongue and facial muscles decreases the patient’s ability to socialize or communicate needs. Disuse syndrome is not an appropriate nursing diagnosis because the patient is continuing to use the muscles as much as possible. There is no indication in the stem that the patient has a self-care deficit, bradykinesia, or rigidity. The oral mucous membranes will continue to be moist and should not be impaired by the patient’s difficulty swallowing.
A patient has a new prescription for levodopa (L-dopa) to control symptoms of Parkinson’s disease. Which assessment data obtained by the nurse may indicate a need for a decrease in the dose?
Hypotension is an adverse effect of L-dopa, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with L-dopa use.
A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the patient’s
Because the patient’s respiratory insufficiency is life threatening, it will be most important to monitor respiratory function during the Tensilon test. Pupillary size and muscle strength may also be affected by the test but are not as important to monitor. LOC is not typically affected by MG, although the LOC may be affected by oxygenation in this patient.
When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to
Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for in situations where corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.
A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals the patient should avoid
The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals. The other activities will not affect the muscles used for chewing and swallowing.
A patient with restless legs syndrome (RLS) tells the nurse, “My leg pain and twitching keep me awake so much of the night, I am tired most of the day. Is there anything I can do?” Based on this information, which nursing diagnosis is most appropriate?
The patient’s statement indicates that daytime fatigue caused by lack of sleep is the major concern. The patient does not indicate concern with role performance. Although pain is a concern with RLS, the patient’s concern is with the impact of pain on sleep. The patient is asking for information about treatment but does not appear anxious.
A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient’s ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
A 42-year-old patient who was adopted at birth is diagnosed with early Huntington’s disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the
: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. The patient is at risk for pneumonia in the later stages of HD, but this patient has early HD. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.
A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
Which information obtained about a 75-year-old patient with new-onset seizures will be of concern to the nurse when the patient is being started on therapy with phenytoin (Dilantin)?
Phenytoin is metabolized by the liver, and the patient’s age and history of hepatitis may increase the risk for toxic effects. The patient’s age at menopause, living in an assisted living facility, and stroke history do not increase the risk for adverse effects of phenytoin.
A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling–type tremor. The nurse will anticipate teaching the patient about
The diagnosis of Parkinson’s is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson’s disease, and corticosteroid therapy is not used to treat it.
When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? (Select all that apply.)
: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed’s side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated.
A patient with Parkinson’s disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? (Select all that apply.)
Since the patient with Parkinson’s has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson’s is a steadily progressive disease without acute exacerbations. Bradykinesia associated with ambulation is relieved by asking the patient to step over imaginary lines or rice kernels on the floor.
Chapter 60: Nursing Management: Alzheimer’s Disease and Dementia
A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia?
The onset of delirium occurs acutely. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.
When developing a plan of care for a hospitalized patient with moderate dementia, which intervention will the nurse include?
The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.
When administering a mental status examination to a patient with delirium, the nurse should
Because overstimulation by environmental factors can distract the patient from the task of answering the nurse’s questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient’s delirium.
To protect a patient from injury during an episode of delirium, the most appropriate action by the nurse is to
The priority goal is to protect the patient from harm, and a staff member will be most experienced in providing safe care. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have multiple side effects. Restraints are sometimes used but tend to increase agitation and disorientation.
A family member of a patient with possible Alzheimer’s disease asks the nurse the purpose of the Mini-Mental State Examination (MMSE). Which response by the nurse is appropriate?
The MMSE establishes the degree of mental impairment at the time it is given. It does not establish a diagnosis of AD but when given repeatedly over time may help to determine the progression of AD. The choice of treatment is made on the basis of multiple data, not just the MMSE. The MMSE may be abnormal with either delirium or dementia and is not useful in determining which condition the patient has.
When administering a mental status examination to a patient, the nurse suspects depression when the patient responds with
A 71-year-old patient is diagnosed with moderate dementia as a result of multiple strokes. During assessment of the patient, the nurse would expect to find
Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient’s ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.
Coexisting dementia and depression are identified in a patient with Parkinson’s disease. The nurse anticipates that the greatest improvement in the patient’s condition will occur with administration of
Parkinson’s disease and depression are both potentially reversible conditions, and the patient’s symptoms that are caused by these two conditions will improve with appropriate treatment. Anticholinergic agents are likely to worsen the patient’s condition because they will block the effect of acetylcholine at the synaptic cleft. There is no indication that the patient needs an antipsychotic agent at this time. A selective serotonin reuptake inhibitor (SSRI) may be effective for the depression, but it does not address the patient’s other conditions.
A 62-year-old patient is brought to the clinic by a family member who is concerned about the patient’s increasing sleep disturbances and inability to solve common problems. To obtain information about the patient’s current mental status, which question should the nurse ask the patient?
This question tests the patient’s orientation to time, which is decreased in early Alzheimer’s disease (AD) or dementia. Asking the patient about birthplace tests for remote memory, which is intact in the early stages. Questions about the patient’s emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.
When teaching the spouse of a patient who is being evaluated for Alzheimer’s disease (AD) about the disorder, the nurse explains that
The diagnosis of AD is one of exclusion. Age is the most important risk factor for development of AD. Drugs can slow the deterioration but do not dramatically reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well.
A home-health patient with Alzheimer’s disease (AD) and mild dementia has a new prescription for donepezil (Aricept). Which nursing action will be most effective in ensuring compliance with the medication?
Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the Aricept. The other nursing actions will not be as effective in ensuring that the patient takes the medications.
Risperidone (Risperdal) is prescribed for an outpatient with moderate Alzheimer’s disease (AD). Which information obtained by the nurse at the next clinic appointment indicates that the medication is effective?
Risperidone is an antipsychotic used to treat the agitation, aggression, and behavioral problems associated with AD. The other improvements might occur with cholinesterase inhibitors.
The nurse has identified the nursing diagnosis of disturbed thought processes related to effects of dementia for a patient with late-stage Alzheimer’s disease (AD). An appropriate intervention for this problem is to
Providing a consistent routine will decrease anxiety and confusion for the patient. In late-stage AD, the patient will not remember events from the past. Reorientation to time and place will not be helpful to the patient with late-stage AD. The patient with late-stage AD will not be able to read.
A patient with Alzheimer’s disease (AD) is hospitalized with a urinary tract infection. The spouse tells the nurse, “I am just exhausted from the constant care and worry. We don’t have any children and we can’t afford a nursing home. I don’t know what to do.” The most appropriate nursing diagnosis for the spouse is
The spouse’s statements are most consistent with caregiver role strain. The other diagnoses each address one aspect of the spouse’s problem, but caregiver-role strain related to limited resources for caregiving addresses all the information the nurse has about this situation.
A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse’s initial action should be to
Increased motor activity in a patient with dementia is frequently the patient’s only way of responding to factors like pain, so the nurse’s initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning a nursing assistant to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.
When assessing a patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action will the nurse include in the plan of care?
Patients at risk for problems with safety require close supervision. Placing the patient near the nurse’s station will allow nursing staff to observe the patient more closely. Use of “why” questions is frustrating for the patient with AD, who are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient’s short-term memory loss, reorientation will not help to prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.
During the morning change-of-shift report at the long-term care facility, the nurse learns that the patient with dementia has had sundowning. Which nursing action should the nurse take while caring for the patient?
The most likely cause of sundowning is a disruption in circadian rhythms and keeping the patient active and in daylight will help to reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with memory difficulties.
Chapter 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems
When assessing a patient with newly diagnosed trigeminal neuralgia, the nurse will ask the patient about
The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and numbness are not characteristics of trigeminal neuralgia, although ptosis and numbness may occur after therapy, and poor appetite may be associated with pain stimulated by eating.
During assessment of the patient with a recurrence of symptoms of trigeminal neuralgia, the nurse should
Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
A patient with trigeminal neuralgia has a glycerol rhizotomy. During a follow-up visit after the rhizotomy, the nurse will evaluate that the patient has had a successful outcome for the surgery if the patient
: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, enjoyment of social activities indicates successful reduction of symptoms. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
When teaching patients who are at risk for Bell’s palsy because of previous herpes simplex infection, which information should the nurse include?
Pain or herpes lesions near the ear may indicate the onset of Bell’s palsy and rapid corticosteroid treatment may reduce the duration of Bell’s palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell’s palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell’s palsy.
A patient with Bell’s palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse to the patient’s behavior is to
The patient’s desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient’s enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient’s embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome
: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.
A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s illness, the most essential assessment for the nurse to carry out is
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.
When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include
Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
A patient admitted to the emergency department is diagnosed with botulism, and an order for botulinum antitoxin is received. Before administering the antitoxin, it is most important for the nurse to
To prevent allergic reactions, an intradermal test dose of the antitoxin should be administered. Although baseline vital signs, allergy history, and symptom assessment and documentation are appropriate, these assessments will not impact on the decision to administer the antitoxin.
A patient arrives at an urgent care center with a deep puncture wound after stepping on a nail that was embedded in some old lumber in a field. The patient reports having had a tetanus booster 7 years ago. The nurse will anticipate
If the patient has not been immunized within 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. A test dose is not needed for immune globulin, and TIG is not indicated for the patient.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding
Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to
: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient’s ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse’s first action.
As a result of a gunshot wound, a patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient’s left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that
The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess
The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?
: Because the patient’s bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient’s incontinence.
A patient with a history of a T2 spinal cord tells the nurse, “I feel awful today. My head is throbbing, and I feel sick to my stomach.” Which action should the nurse take first?
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is causing the symptoms, including hypertension. Notification of the patient’s health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where “they know what they are doing.” The best response by the nurse to the patient’s behavior is to
The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient’s anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient’s input into what care is needed.
A 26-year-old patient with a C8 spinal cord injury tells the nurse, “My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually.” The most appropriate response by the nurse to the patient’s comment is to
Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient’s sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient’s spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient’s ongoing care need to feel that their input is important, telling the family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
The nurse is caring for a patient who is being evaluated for a possible metastatic spinal cord tumor. Which of these data obtained when assessing the patient requires most immediate action by the nurse?
The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.
Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?
Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.
A patient with possible botulism poisoning is admitted for observation and administration of botulinum antitoxin. Which of the following health care provider orders should the nurse question?
Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory function. The other actions are also appropriate but are not as important as assessment of respiratory effort.
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? (Select all that apply.)
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient’s head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
The first action should be to prevent further injury by stabilizing the patient’s spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
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