1.
SITUATION: Mr. Ambo is a 75 year old man with Parkinson’s disease. He is admitted to the hospital after experiencing severe nightmare and periods of confusion. During lucid periods, he is very disturbed by these manifestations. At other time, he believes that his wife is participating in a conspiracy to harm him
Degenerative neurologic disorders pose a great challenge to the client, the family, and the caregiver. Which is true about Parkinson’s disease?
Correct Answer
B. It is an idiopathic syndrome characterized by disability from tremor and rigidity
Explanation
Parkinson's disease is an idiopathic syndrome, meaning its cause is unknown. It is characterized by disability from tremor and rigidity. This means that individuals with Parkinson's disease experience symptoms such as shaking/tremors and stiffness in their muscles, which can significantly impact their ability to move and perform daily activities. The disease is not caused by inflammation, an infectious agent like Cytomegalovirus, or the degeneration of the myelin sheath of peripheral nerves. The degeneration of nor-epinephrine-producing cells in the substantia nigra is also not a characteristic of Parkinson's disease.
2.
SITUATION: Mr. Ambo is a 75 year old man with Parkinson’s disease. He is admitted to the hospital after experiencing severe nightmare and periods of confusion. During lucid periods, he is very disturbed by these manifestations. At other time, he believes that his wife is participating in a conspiracy to harm him
During her initial assessment, the nurse observes which cardinal features of Parkinson’s disease? Select all that apply:
1. Freezing movement;
2. Paranoia;
3. Flexed posture of the neck, trunk and limbs;
4. Hallucinations;
5. Tremor at rest;
6. Rigidity
Correct Answer
A. 1, 3, 5, 6
Explanation
The nurse observes the cardinal features of Parkinson's disease, which include freezing movement, flexed posture of the neck, trunk, and limbs, tremor at rest, and rigidity. These symptoms are commonly seen in patients with Parkinson's disease and can significantly impact their daily functioning and quality of life. Paranoia and hallucinations are not cardinal features of Parkinson's disease, although they may occur in some patients as a result of the disease or medication side effects.
3.
SITUATION: Mr. Ambo is a 75 year old man with Parkinson’s disease. He is admitted to the hospital after experiencing severe nightmare and periods of confusion. During lucid periods, he is very disturbed by these manifestations. At other time, he believes that his wife is participating in a conspiracy to harm him
Can the client’s manifestations be related to treatment or to some other cause other than Parkinson’s disease?
Correct Answer
B. Yes, it can be a manifestation of Alzheimer’s disease
Explanation
The client's manifestations of severe nightmares, periods of confusion, and belief in a conspiracy can be symptoms of Alzheimer's disease. While Parkinson's disease primarily affects motor abilities, it can also lead to cognitive decline and dementia. However, the specific symptoms described in the situation are more commonly associated with Alzheimer's disease, which is characterized by memory loss, confusion, and paranoia.
4.
SITUATION: Mr. Ambo is a 75 year old man with Parkinson’s disease. He is admitted to the hospital after experiencing severe nightmare and periods of confusion. During lucid periods, he is very disturbed by these manifestations. At other time, he believes that his wife is participating in a conspiracy to harm him
The nurse observes changes in behavior on the patient and proceeds with a focused assessment to differentiate dementia and delirium. Choose all the assessments that are unique to delirium:
1. Impaired judgment;
2. Intervals of lucidity;
3. Distorted perceptions;
4. Hyperkinetic behavior;
5. Abrupt onset of symptoms
Correct Answer
C. 2, 4, 5
Explanation
The assessments that are unique to delirium in this situation are intervals of lucidity, hyperkinetic behavior, and abrupt onset of symptoms. Impaired judgment and distorted perceptions can be seen in both dementia and delirium, so they are not unique to delirium.
5.
SITUATION: Mr. Ambo is a 75 year old man with Parkinson’s disease. He is admitted to the hospital after experiencing severe nightmare and periods of confusion. During lucid periods, he is very disturbed by these manifestations. At other time, he believes that his wife is participating in a conspiracy to harm him
The nurse evaluates the health teaching on a client with Parkinson’s disase. Further teaching is required when the nurse observes the following, except:
Correct Answer
A. The client grips the arms of the chair to reduce embarrassing hand tremors
Explanation
The client gripping the arms of the chair to reduce hand tremors is an appropriate action for someone with Parkinson's disease. Tremors are a common symptom of the disease, and gripping onto something can help stabilize the hands. The other options are all potential areas where further teaching may be required. Range of motion exercises should be done daily, not just 3 times a week, to maintain flexibility and prevent muscle stiffness. The mattress being bouncy and soft may not provide enough support for someone with Parkinson's, who may have difficulty with balance and coordination. Sleeping with two piles of pillows under the head can cause strain on the neck and may not provide proper support for sleep.
6.
SITUATION: A 34 year old woman with myasthenia gravis is taking pyridostigmine and prednisone. She is complaining of increased fatigue and weakness and has difficulty breathing
Nurse Ludy knowledgeably tells a student nurse that the primary feature of Myasthenia Gravis is:
Correct Answer
B. Increasing weakness with sustained muscle contraction
Explanation
The primary feature of Myasthenia Gravis is increasing weakness with sustained muscle contraction. This means that the patient experiences progressive muscle weakness and fatigue, particularly during activities that require continuous muscle use. This symptom is characteristic of the disease and distinguishes it from other conditions. The patient's complaint of increased fatigue and weakness, along with difficulty breathing, aligns with this primary feature of Myasthenia Gravis.
7.
SITUATION: A 34 year old woman with myasthenia gravis is taking pyridostigmine and prednisone. She is complaining of increased fatigue and weakness and has difficulty breathing
A nurse observes a patient when the physician does the diagnostic test to confirm MG. The physician injects 2 mg test does of Edrophonium to the client. No untoward reaction occurred. Another 8 mg was injected and the patient suddenly lifts his weak hand without difficulty. The nurse knows that which test was done to diagnose MG?
Correct Answer
D. Tensilon test
Explanation
The Tensilon test was done to diagnose MG. The physician injected a test dose of Edrophonium, a short-acting cholinesterase inhibitor, to the patient. When an additional dose of 8 mg was injected, the patient suddenly lifted their weak hand without difficulty. This positive response indicates that the patient has myasthenia gravis, as Edrophonium temporarily improves muscle strength in individuals with MG. The Tensilon test is commonly used to confirm the diagnosis of MG.
8.
SITUATION: A 34 year old woman with myasthenia gravis is taking pyridostigmine and prednisone. She is complaining of increased fatigue and weakness and has difficulty breathing
The nurse in the emergency department is suspecting a cholinergic crisis from the patient with myasthenia gravis. Aside from weakness and difficulty of breathing, what other signs and symptoms will the nurse anticipate:
Correct Answer
D. Apprehension, nausea, vomiting and abdominal cramps
Explanation
In a cholinergic crisis, there is an excessive accumulation of acetylcholine due to overmedication with cholinesterase inhibitors like pyridostigmine. This leads to excessive stimulation of cholinergic receptors throughout the body, resulting in symptoms such as weakness, difficulty breathing, and increased fatigue. Additionally, cholinergic crisis can cause gastrointestinal symptoms such as nausea, vomiting, and abdominal cramps. Apprehension may also occur due to the respiratory distress caused by the crisis. Therefore, the nurse can anticipate these signs and symptoms in a patient experiencing a cholinergic crisis.
9.
SITUATION: A 34 year old woman with myasthenia gravis is taking pyridostigmine and prednisone. She is complaining of increased fatigue and weakness and has difficulty breathing
The nurse caring for this patient would do which of the following first?
Correct Answer
A. Providing adequate ventilatory support
Explanation
The patient's increased fatigue, weakness, and difficulty breathing indicate a potential respiratory distress, which can be life-threatening. Providing adequate ventilatory support should be the first priority to ensure the patient's oxygenation and ventilation. Discontinuing cholinergic drugs, administering atropine, or increasing cholinergic drug doses may be appropriate interventions in certain situations, but they do not address the immediate need for ventilatory support.
10.
SITUATION: A 34 year old woman with myasthenia gravis is taking pyridostigmine and prednisone. She is complaining of increased fatigue and weakness and has difficulty breathing
The patient’s MG is in its early course. The physician recommends a thymectomy. The nurse in the surgical ward is preparing the client for surgery. Which action by the nurse will denote a violation of the bio-ethical principle non-maleficence?
Correct Answer
D. Letting the patient void after giving preoperative medications
Explanation
Letting the patient void after giving preoperative medications may denote a violation of the bio-ethical principle of non-maleficence because it can increase the risk of aspiration during surgery. It is important to ensure that the patient's bladder is empty before surgery to minimize the risk of complications.
11.
SITUATION: A 35 year old female, wheelchair bound, is diagnosed with multiple sclerosis. She has a neurogenic bladder. She complains of a sudden onset of generalized weakness, fever, and chills and is admitted to the hospital
A variety of precipitating factors can precede the onset or an exacerbation of Multiple sclerosis. All of the following are precipitating factors of MS, except:
Correct Answer
B. Lactation
Explanation
Lactation is not a precipitating factor of multiple sclerosis. Pregnancy, physical injury, and emotional stress are known to be precipitating factors that can trigger the onset or exacerbation of MS symptoms. However, lactation, which is the production of breast milk after childbirth, is not typically associated with the onset or exacerbation of MS symptoms.
12.
SITUATION: A 35 year old female, wheelchair bound, is diagnosed with multiple sclerosis. She has a neurogenic bladder. She complains of a sudden onset of generalized weakness, fever, and chills and is admitted to the hospital
The most appropriate nursing diagnosis that a nurse could formulate regarding this client is:
Correct Answer
A. Impaired pHysical mobility related to generalized weakness
Explanation
The most appropriate nursing diagnosis for this client is "Impaired physical mobility related to generalized weakness" because the client is experiencing sudden onset of weakness, which can affect her ability to move and perform activities of daily living. This nursing diagnosis addresses the client's current physical condition and the potential impact it may have on her mobility.
13.
SITUATION: A 35 year old female, wheelchair bound, is diagnosed with multiple sclerosis. She has a neurogenic bladder. She complains of a sudden onset of generalized weakness, fever, and chills and is admitted to the hospital
With the patient’s alteration in urinary elimination, the nurse conducts a health teaching to the client regarding self catheterization. Which statement when made by the client denotes effective teaching?
Correct Answer
D. “After using the catheter I should wash it thoroughly with soap and water and keep it in a clean, tightly sealed plastic bag”
Explanation
The correct answer is "After using the catheter I should wash it thoroughly with soap and water and keep it in a clean, tightly sealed plastic bag". This statement denotes effective teaching because it emphasizes the importance of proper cleaning and storage of the catheter to prevent infection. Washing the catheter with soap and water helps to remove any bacteria or debris, and storing it in a clean, sealed bag helps to maintain its sterility. This demonstrates the client's understanding of the necessary steps for self-catheterization hygiene.
14.
SITUATION: A 35 year old female, wheelchair bound, is diagnosed with multiple sclerosis. She has a neurogenic bladder. She complains of a sudden onset of generalized weakness, fever, and chills and is admitted to the hospital
What do generalized weakness, fever and chills suggest to any client with MS?
Correct Answer
C. Fever and chills suggest infection that caused the exacerbation of MS leading to weakness
Explanation
The presence of fever and chills in a client with multiple sclerosis suggests an infection that has caused the exacerbation of their MS symptoms, leading to weakness. Infections can trigger or worsen MS symptoms, and the sudden onset of generalized weakness along with the presence of fever and chills indicates an infectious process. It is important to address and treat the infection to help alleviate the exacerbation of MS symptoms and improve the client's overall condition.
15.
SITUATION: A 35 year old female, wheelchair bound, is diagnosed with multiple sclerosis. She has a neurogenic bladder. She complains of a sudden onset of generalized weakness, fever, and chills and is admitted to the hospital
With the nursing diagnosis of knowledge deficit related to diagnosis of MS. The nurse reiterates the following interventions to prevent exacerbations of MS to the patient, except:
Correct Answer
C. Confront people who are making her life miserable and try to resolve it
Explanation
The correct answer is "Confront people who are making her life miserable and try to resolve it." This is not a recommended intervention for preventing exacerbations of MS. It is important for the patient to identify aggravating factors that lead to exacerbations, increase their body's resistance to illness with intake of citrus fruits, and avoid stressors such as tiring activities and having a negative outlook in life. However, confronting people who are making her life miserable may not be within the patient's control and may not necessarily prevent exacerbations of MS.
16.
SITUATION: The diagnosis of degenerative neurologic disease is most often made in an out-patient setting. However, hospital admission may be necessary when acute relapses or life-threatening events occur
Guillain-Barre syndrome is an inflammatory disease of unknown origin. Although many organism have been suspected, Campylobacter jejuni is the organism most often implicated. This gram-negative rod is found in:
Correct Answer
B. Poultry
Explanation
Poultry is the correct answer because Campylobacter jejuni, the organism most often implicated in Guillain-Barre syndrome, is commonly found in poultry. This suggests that consuming contaminated poultry products may increase the risk of developing the syndrome.
17.
SITUATION: The diagnosis of degenerative neurologic disease is most often made in an out-patient setting. However, hospital admission may be necessary when acute relapses or life-threatening events occur
Mr. Noble is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Nurse Patty inquires during the nursing admission interview if the client has a history of:
Correct Answer
A. Respiratory or gastrointestinal infection during the previous month
Explanation
The nurse is asking about a history of respiratory or gastrointestinal infection during the previous month because Guillain-Barre syndrome is often preceded by an infection, most commonly a respiratory or gastrointestinal infection. This information is important because it helps to establish a potential trigger for the development of Guillain-Barre syndrome.
18.
SITUATION: The diagnosis of degenerative neurologic disease is most often made in an out-patient setting. However, hospital admission may be necessary when acute relapses or life-threatening events occur
The patient has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse brings which of the following items into the client’s room?
Correct Answer
B. ElectrocardiograpHic monitoring electrodes and intubation tray
Explanation
The patient's ascending paralysis to the level of the waist suggests a possible neurologic emergency, such as Guillain-Barre syndrome. This condition can lead to respiratory distress and the need for intubation. Electrocardiographic monitoring electrodes are necessary to monitor the patient's cardiac status, as autonomic dysfunction can occur. Therefore, bringing electrocardiographic monitoring electrodes and an intubation tray into the client's room would be appropriate in this situation.
19.
SITUATION: The diagnosis of degenerative neurologic disease is most often made in an out-patient setting. However, hospital admission may be necessary when acute relapses or life-threatening events occur
Mr. Noble has ascending paralysis and is intubated and is receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
Correct Answer
B. Providing information, giving postage feedback, and encouraging relaxation
Explanation
The nurse would incorporate the strategy of providing information, giving positive feedback, and encouraging relaxation in the plan of care to help the client cope with the illness of ascending paralysis and mechanical ventilation. This approach aims to empower the client with knowledge about their condition, which can reduce anxiety and improve their ability to cope. Giving positive feedback can boost the client's morale and motivation. Encouraging relaxation techniques can help the client manage stress and promote a sense of calmness.
20.
SITUATION: The diagnosis of degenerative neurologic disease is most often made in an out-patient setting. However, hospital admission may be necessary when acute relapses or life-threatening events occur
Nurse Ofelia is evaluating the respiratory outcomes for the client. She determines that which of the following is the least optimal outcome for the client?
Correct Answer
B. Adventitious breath sounds
Explanation
Adventitious breath sounds indicate abnormal lung sounds, such as crackles or wheezes, which can be a sign of respiratory distress or underlying lung pathology. In the context of a client with degenerative neurologic disease, the presence of adventitious breath sounds suggests a worsening of respiratory function and may indicate a need for further intervention or medical attention. Therefore, adventitious breath sounds would be considered the least optimal outcome for the client.
21.
SITUATION: By their very nature, degenerative neurologic disorders cause progressive decline in neurologic function. Some progress relatively quickly whereas others progress more gradually, sometimes over decades. A major goal intervention is to help client achieve an optimal level of functioning in light of chronic neurologic deficits
Eaton-Lambert (Myasthenic) syndrome is a myasthenia-like condition in which weakness is noted in the limbs. Because MG can precede the development of cancer by many years, clients with this syndrome should be assessed for the development of cancer:
Correct Answer
A. Yearly
Explanation
Clients with Eaton-Lambert (Myasthenic) syndrome should be assessed for the development of cancer on a yearly basis. This is because myasthenia gravis (MG) can precede the development of cancer by many years. Regular assessments are important to detect any potential cancer development in these clients.
22.
SITUATION: By their very nature, degenerative neurologic disorders cause progressive decline in neurologic function. Some progress relatively quickly whereas others progress more gradually, sometimes over decades. A major goal intervention is to help client achieve an optimal level of functioning in light of chronic neurologic deficits
Supportive nursing care is an important aspect of managing Amyotrophic Lateral Sclerosis (ALS). Which is the most therapeutic intervention of the community health nurse when interacting with the client and the client’s family?
Correct Answer
B. Instruct patient on how to use a walker
Explanation
The most therapeutic intervention of the community health nurse when interacting with the client and the client's family in managing ALS is to instruct the patient on how to use a walker. This intervention helps the client maintain mobility and independence, which is crucial in managing the progressive decline in neurologic function associated with ALS. By providing instruction on using a walker, the nurse supports the client's optimal level of functioning and helps them adapt to their chronic neurologic deficits.
23.
SITUATION: By their very nature, degenerative neurologic disorders cause progressive decline in neurologic function. Some progress relatively quickly whereas others progress more gradually, sometimes over decades. A major goal intervention is to help client achieve an optimal level of functioning in light of chronic neurologic deficits
A 40 year old man, diagnosed with Huntington’s disease chorea, was brought to the hospital. He is emaciated as a result of dysphagia. Which of the following nursing interventions is not appropriate?
Correct Answer
C. Small frequent feedings should be avoided
Explanation
Small frequent feedings should be avoided. This is not an appropriate nursing intervention because the patient is emaciated as a result of dysphagia. Dysphagia is difficulty in swallowing, and in this case, it has caused the patient to become emaciated. Small frequent feedings are typically recommended for patients with dysphagia to prevent choking and aspiration. Therefore, avoiding small frequent feedings would not be beneficial for the patient's condition.
24.
SITUATION: By their very nature, degenerative neurologic disorders cause progressive decline in neurologic function. Some progress relatively quickly whereas others progress more gradually, sometimes over decades. A major goal intervention is to help client achieve an optimal level of functioning in light of chronic neurologic deficits
A 72 year old female client has Alzheimer’s disease. Her caregiver phones the community health clinic and asks the nurse some advice on the care of this patient, all of the following are inappropriate, except:
Correct Answer
B. Encourage caregivers to share their knowledge and experience with newly assigned health care staff
Explanation
The correct answer is "Encourage caregivers to share their knowledge and experience with newly assigned health care staff." This is inappropriate because it does not align with the goal of helping the client achieve an optimal level of functioning. Sharing knowledge and experience with newly assigned staff may not be helpful in improving the client's condition or providing appropriate care.
25.
SITUATION: By their very nature, degenerative neurologic disorders cause progressive decline in neurologic function. Some progress relatively quickly whereas others progress more gradually, sometimes over decades. A major goal intervention is to help client achieve an optimal level of functioning in light of chronic neurologic deficits
A client is experiencing chronic insomnia. The nurse interprets that which of the following areas of the brain is involved?
Correct Answer
D. Reticular activating system and cerebral hemispHeres
Explanation
The nurse interprets that the reticular activating system and cerebral hemispheres are involved in chronic insomnia. The reticular activating system is responsible for regulating wakefulness and sleep-wake transitions, while the cerebral hemispheres play a role in controlling sleep patterns and maintaining a regular sleep-wake cycle. Dysfunction in these areas can lead to difficulty falling asleep or staying asleep, resulting in chronic insomnia.