chapter 63 Flashcards
The nurse is assessing a client with newly diagnosed trigeminal neuralgia. Which of the
following parameters should the nurse assess?
a. Triggers that lead to facial pain
b. Visual problems caused by ptosis
c. Poor appetite caused by a loss of taste
d. Weakness on the affected side of the face
A
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 facial weakness
are not characteristics of trigeminal neuralgia.
Which of the following actions should the nurse take when assessing a client with
trigeminal neuralgia?
a. Examine the mouth and teeth thoroughly.
b. Have the client clench and relax the jaw and eyes.
c. Identify trigger zones by lightly touching the affected side.
d. Gently palpate the face to compare skin temperature bilaterally.
A
Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the
client 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.
The nurse is caring for a client with trigeminal neuralgia who has had a glycerol rhizotomy.
Which of the following interventions should the nurse implement?
a. Ask whether the client is using an eye shield at night.
b. Determine whether the client is doing daily facial exercises.
c. Question the client about social activities with family and friends.
d. Remind the client to chew food on the unaffected side of the mouth.
C
Because withdrawal from social activities is a common manifestation of trigeminal
neuralgia, asking about social activities will help in evaluating whether the client’s
symptoms have improved. 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.
Which of the following actions should the nurse include in the plan of care when caring
for a client who is experiencing trigeminal neuralgia?
a. Teach facial and jaw relaxation techniques.
b. Assess intake and output and dietary intake.
c. Apply ice packs for no more than 20 minutes.
d. Spend time at the bedside talking with the client.
B
The client 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 client will not want to
engage in conversation, which may precipitate attacks.
The nurse is teaching a client who is at risk for Bell’s palsy because of previous herpes
simplex infection. Which of the following information should the nurse include?
a. “Call the doctor if pain or herpes lesions occur near the ear.”
b. “Treatment of herpes with antiviral agents prevents Bell’s palsy.”
c. “You may be able to prevent Bell’s palsy by doing facial exercises regularly.”
d. “Medications to treat Bell’s palsy work only if started before paralysis onset.”
A
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.
The nurse is caring for a client with Bell’s palsy who refuses to eat while others are
present because of embarrassment about drooling. Which of the following responses is
best for the nurse to do?
a. Respect the client’s desire and arrange for privacy at mealtimes.
b. Teach the client to chew food on the unaffected side of the mouth.
c. Offer the client liquid nutritional supplements at frequent intervals.
d. Discuss the client’s concerns with visitors who arrive at mealtimes.
A
The client’s desire for privacy should be respected to encourage adequate nutrition and
reduce client embarrassment. Liquid supplements will reduce the client’s enjoyment of the
taste of food. It would be inappropriate for the nurse to discuss the client’s embarrassment
with visitors unless the client 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.
Which of the following nursing actions should the home health nurse include in the plan of
care for a client with paraplegia in order to prevent autonomic dysreflexia?
a. Assist with selection of a high protein diet.
b. Use quad coughing to assist cough effort.
c. Discuss options for sexuality and fertility.
d. Teach the purpose of a prescribed bowel program.
D
Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may
be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following
assessment data obtained by the nurse will require the most immediate action?
a. The client has continuous drooling of saliva.
b. The client’s blood pressure (BP) is 106/50 mm Hg.
c. The client’s quadriceps and triceps reflexes are absent.
d. The client complains of severe tingling pain in the feet.
A
Drooling indicates decreased ability to swallow, which places the client 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.
The nurse is caring for a client who has numbness and weakness of both feet and who is
hospitalized with Guillain-Barré syndrome. Which of the following information should the
nurse include in the client’s plan of care?
a. Intubation and mechanical ventilation
b. Administration of IV corticosteroid drugs
c. Insertion of a nasogastric (NG) feeding tube
d. IV infusion of high dose immunoglobulin (IVIG)
D
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 client arrives at an urgent care centre with a deep puncture wound after stepping on a
nail that was lying on the ground. The client reports having had a tetanus booster 7 years
ago. Which of the following actions should the nurse anticipate?
a. IV infusion of tetanus immune globulin (TIG)
b. Administration of the tetanus-diphtheria (Td) booster
c. Intradermal injection of an immune globulin test dose
d. Initiation of the tetanus-diphtheria immunization series
B
If the client has not been immunized within 5 years and presents with an open wound,
administration of the Td booster is indicated because the wound is deep. Immune globulin
administration is given by the IM route if the client has no previous immunization.
Administration of a series of immunization is not indicated. TIG is not indicated for this
client, and a test dose is not needed for immune globulin.
The nurse is caring for a client with a neck fracture at the C5 level in the intensive care
unit. During initial assessment of the client, the nurse recognizes the presence of
neurogenic shock upon assessing which of the following findings?
a. Hypotension, bradycardia, and warm extremities
b. Involuntary, spastic movements of the arms and legs
c. Hyperactive reflex activity below the level of the injury
d. Lack of movement or sensation below the level of the injury
A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading
to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of
spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not
neurogenic shock.
The nurse is caring for a client who has an incomplete right spinal cord lesion at the level
of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions
should be included in the plan of care?
a. Assessment of the client for left leg pain
b. Assessment of the client for left arm weakness
c. Positioning the client’s right leg when turning the client
d. Teaching the client to look at the left leg to verify its position
C
The client 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 client’s
left leg. Left arm weakness will not be a problem for a client with a T7 injury. The client
will retain position sense for the left leg.
The nurse is caring for a client with a T1 spinal cord injury in the intensive care unit.
Which of the following information should the nurse include in the teaching plan for the
client and family?
a. Use of the shoulders will be preserved.
b. Full function of the client’s arms will be retained.
c. Total loss of respiratory function may occur temporarily.
d. Elevations in heart rate are common with this type of injury.
B
The client 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. Loss of respiratory
function occurs with cervical spine injuries. Bradycardia is associated with injuries above
the T6 level.
The nurse is caring for a client with paraplegia resulting from a T10 spinal cord injury who
has a neurogenic reflex bladder. Which of the following actions should the nurse include
in the plan of care?
a. Educate on the use of the Credé method.
b. Teach the client how to self-catheterize.
c. Catheterize for residual urine after voiding.
d. Assist the client to the toilet every 2 hours.
B
Because the client’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 client 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 client’s incontinence.
The nurse is developing a rehabilitation plan for a client with a C6 spinal cord injury.
Which of the following goals should the nurse include for this client?
a. Transfer independently to a wheelchair.
b. Drive a car with powered hand controls.
c. Turn and reposition independently when in bed.
d. Push a manual wheelchair on flat, smooth surfaces.
D
The client 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 client will not
be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or
turn independently in bed.
