Nokea
A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. In the early stages, people with the disease can participate in most physical activities.
- B. The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements.
- C. Disease-modifying medications for Huntington disease can decrease immune cells and infection protection.
- D. There are specific tests that can be arranged to diagnose whether or not you have the disorder.
- E. Huntington disease is familial; it is not transmitted genetically.
Correct Answer: A,B,C
Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching.
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A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
- A. Blood pressure 100/60 mm Hg
- B. Lethargy
- C. Nausea
- D. Periorbital edema
Correct Answer: B
Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.
The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
- A. Damage to the nerves that facilitate vision and hearing
- B. Damage to the vagal nerve
- C. Damage to the olfactory nerve
- D. Damage to the facial nerve
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
- A. Dextrose 5% in water (D5W)
- B. Half-normal saline (0.45% NSS)
- C. One-third normal saline (0.33% NSS)
- D. Lactated Ringer's
Correct Answer: D
Rationale: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?
- A. Avoid stimuli that trigger pain.
- B. Use ophthalmic lubricant and protect the eye.
- C. Encourage semiannual dental exams.
- D. Complete the course of antibiotics as prescribed.
Correct Answer: B
Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.