Lewis: Chapter 58: Chronic Neurologic Problems

Question 1

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following?

a. “I can take the (Topamax) as soon as a headache starts.”
b. “A glass of wine might help me relax and prevent a headache.”
c. “I will lie down someplace dark and quiet when the headaches begin.”
d. “I should avoid taking aspirin and sumatriptan (Imitrex) at the same time.”

Answer 1

ANS: C
It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines. It must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

Question 2

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache?

a. Nuchal rigidity
b. Unilateral ptosis
c. Projectile vomiting
d. Bilateral facial pain

Answer 2

ANS: B
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 increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Question 3

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the patient’s arms and legs to prevent injury during the seizure.
c. Time and observe and record the details of the seizure and postictal state.
d. Avoid touching the patient to prevent further nervous system stimulation.

Answer 3

ANS: C
Because the 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.

Question 4

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” How should the nurse respond to specifically address the patient’s concern?

a. “You might benefit from some psychologic counseling.”
b. “Epilepsy usually can be well controlled with medications.”
c. “You will want to contact the Epilepsy Foundation for assistance.”
d. “The Department of Vocational Rehabilitation can help with work retraining.”

Answer 4

ANS: B
The nurse should inform the patient that most seizure disorders are controlled with medication. The other information may be necessary if seizures persist after treatment with antiseizure medications is implemented.

Question 5

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel sounds.
d. Check pupil reaction to light.

Answer 5

ANS: A

Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

Question 6

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure?

a. Focal-onset
b. Atonic
c. Absence
d. Myoclonic

Answer 6

ANS: A
The initial symptoms of a focal-onset seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

Question 7

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)?

a. Assess for the presence of chest pain.
b. Inquire about urinary tract problems.
c. Inspect the skin for rashes or discoloration.
d. Ask the patient about any increase in libido.

Answer 7

ANS: B
Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

Question 8

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond?

a. “MS symptoms will be worse after the pregnancy.”
b. “Women with MS frequently have premature labor.”
c. “Symptoms of MS are likely to improve during pregnancy.”
d. “MS is associated with an increased risk for congenital defects.”

Answer 8

ANS: C
Symptoms of MS may improve during pregnancy. There is no increased risk for congenital defects in infants born of mothers with MS. Onset of labor is not affected by MS. MS symptoms will not worsen after pregnancy.

Question 9

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching?

a. Recommendation to drink at least 4 L of fluid daily
b. Need to avoid driving or operating heavy machinery
c. How to draw up and administer injections of the medication?
d. Use of contraceptive methods other than oral contraceptives

Answer 9

ANS: C
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Question 10

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?

a. The patient reports pain with neck flexion.
b. The patient has increased serum creatinine.
c. The patient walks a mile each day for exercise.
d. The patient has the relapsing-remitting form of MS.

Answer 10

ANS: B
Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

Question 11

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

a. Encourage decreased evening intake of fluid.
b. Teach the patient how to use the Credé method.
c. Suggest the use of adult incontinence briefs for nighttime only.
d. Assist the patient to the commode every 2 hours during the day.

Answer 11

ANS: B
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 and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Question 12

A patient with Parkinson’s disease has bradykinesia. Which action should the nurse include in the plan of care?

a. Instruct the patient in activities that can be done while lying or sitting.
b. Suggest that the patient rock from side to side to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to keep the feet in contact with the floor and slide them forward.

Answer 12

ANS: B
Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Question 13

What should the nurse advise a patient with myasthenia gravis (MG) to do?

a. Anticipate the need for weekly plasmapheresis treatments.
b. Complete physically demanding activities early in the day.
c. Protect the extremities from injury due to poor sensory perception.
d. Perform frequent weight-bearing exercise to prevent muscle atrophy.

Answer 13

ANS: B
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 situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG. Muscle atrophy does not occur because although there is muscle weakness, they are still used.

Question 14

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient?

a. Ibuprofen
b. Multivitamin
c. Acetaminophen
d. Diphenhydramine

Answer 14

ANS: D
Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

Question 15

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care?

a. Observe for agitation and paranoia.
b. Assist with active range of motion (ROM).
c. Give muscle relaxants as needed to reduce spasms.
d. Use simple words and phrases to explain procedures.

Answer 15

ANS: B
ALS causes progressive muscle weakness. Assisting the patient to perform active ROM will
help maintain strength as long as possible. Psychotic manifestations 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

Question 16

A 40-yr-old patient is diagnosed with early Huntington’s disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder?

a. Improved nutrition and exercise can delay disease progression.
b. Levodopa-carbidopa (Sinemet) will help reduce HD symptoms.
c. Prophylactic antibiotics decrease the risk for aspiration pneumonia.
d. Genetic testing is an option for the children to determine their HD risk.

Answer 16

ANS: D
Genetic testing is available to determine whether an asymptomatic person 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 because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

Question 17

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling–type tremor. What should the nurse anticipate explaining to the patient?

a. Oral corticosteroids
b. Antiparkinsonian drugs
c. Magnetic resonance imaging (MRI)
d. Electroencephalogram (EEG) testing

Answer 17

ANS: B
The clinical diagnosis of Parkinson’s is made when tremor, rigidity, akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson’s disease, and corticosteroid therapy is not used to treat it.

Question 18

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?

a. Teach about the use of triptan drugs.
b. Refer the patient for stress counseling.
c. Ask the patient to keep a headache diary.
d. Suggest the use of muscle-relaxation techniques.

Answer 18

ANS: C
The initial nursing action should involve further assessment of precipitating causes of the
headaches, quality, and location of pain. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

Question 19

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially?

a. lorazepam (Ativan)
b. acetaminophen (Tylenol)
c. morphine sulfate (MS Contin)
d. butalbital and aspirin (Fiorinal)

Answer 19

ANS: B
The patient’s symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is 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 butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.

Question 20

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first?

a. Discuss the need to stop taking the acetaminophen.
b. Suggest the use of biofeedback for headache control.
c. Describe the use of botulism toxin (Botox) for headaches.
d. Teach the patient about magnetic resonance imaging (MRI).

Answer 20

ANS: A
The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if the headaches persist.

Question 21

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

a. The patient drinks 1 to 2 cups of coffee daily.
b. The patient had a recent acute myocardial infarction.
c. The patient has had migraine headaches for 30 years.
d. The patient has taken topiramate (Topamax) for 2 months.

Answer 21

ANS: B
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 of it indicates that sumatriptan would be an inappropriate treatment.

Question 22

The nurse observes a patient ambulating in the hospital hall. The patient’s arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first?

a. Assess the patient for a possible injury.
b. Give the scheduled divalproex (Depakote).
c. Document the timing and description of the seizure.
d. Notify the patient’s health care provider about the seizure.

Answer 22

ANS: A
The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the health care provider, and administration of antiseizure medications may also be appropriate actions, but the initial action should be assessment for injury.

Question 23

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

a. Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Administer lorazepam (Ativan) 4 mg IV.
d. Obtain computed tomography (CT) scan.

Answer 23

ANS: C
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. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

Question 24

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?

a. Make referrals to appropriate community agencies.
b. Place medications in the home medication organizer.
c. Teach the patient and family how to manage seizures.
d. Assess for use of medications that may precipitate seizures.

Answer 24

ANS: B
LPN/VN education includes administration of medications. The other activities require RN education and scope of practice.

Question 25

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed?

a. Shuffling gait
b. Tremor at rest
c. Cogwheel rigidity of limbs
d. Uncontrolled head movement

Answer 25

ANS: D
Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson’s disease.

Question 26

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson’s disease and is unable to move the facial muscles?

a. Activity intolerance
b. Inadequate nutrition
c. Disturbed body image
d. Impaired physical mobility

Answer 26

ANS: B
The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson’s disease, but the data do not indicate that they are current problems for this patient.

Question 27

Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis?

a. Pupil size
b. Grip strength
c. Respiratory effort
d. Level of consciousness

Answer 27

ANS: C
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

Question 28

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first?

a. Auscultate the patient’s bowel sounds.
b. Notify the patient’s health care provider.
c. Administer the prescribed PRN antiemetic drug.
d. Give the scheduled dose of prednisone (Deltasone).

Answer 28

ANS: B
The patient’s history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

Question 29

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?

a. Start the prescribed PRN O2 at 6 L/min.
b. Put a moist hot pack on the patient’s neck.
c. Give the ordered PRN acetaminophen (Tylenol).
d. Notify the patient’s health care provider immediately.

Answer 29

ANS: A
Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, 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.

Question 30

Which intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping?

a. Teach about the use of antihistamines to improve sleep.
b. Suggest that the patient exercise regularly during the day.
c. Make a referral to a massage therapist for deep massage of the legs.
d. Assure the patient that the problem is transient and likely to resolve.

Answer 30

ANS: B
Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.

Question 31

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

a. Patient has tonic-clonic seizures.
b. Patient experiences an aura before seizures.
c. Patient’s most recent blood pressure is 156/92 mm Hg.
d. Patient has slight elevations in liver function test results.

Answer 31

ANS: D
Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

Question 32

After change-of-shift report, which patient should the nurse assess first?

a. Patient with myasthenia gravis who is reporting increased muscle weakness.
b. Patient with a bilateral headache described as “like a band around my head.”
c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin).
d. Patient with Parkinson’s disease who has developed cogwheel rigidity of the arms.

Answer 32

ANS: A
Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

Question 33

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room? (Select all that apply.)

a. Side rail pads
b. Tongue blade
c. Oxygen mask
d. Suction tubing
e. Urinary catheter
f. Nasogastric tube

Answer 33

ANS: A, C, D
The patient is at risk for further seizures, and O2 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. Use of tongue blades during a seizure
is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

Question 34

A patient with Parkinson’s disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.)

a. Provide an elevated toilet seat.
b. Cut patient’s food into small pieces.
c. Serve high-protein foods at each meal.
d. Place an armchair at the patient’s bedside.
e. Observe for sudden exacerbation of symptoms.

Answer 34

ANS: A, B, D
Because the patient with Parkinson’s disease 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 disease is a steadily progressive disease without acute exacerbations.