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The nurse is caring for a 30-year-old client diagnosed with amyotrophic lateral sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
- A. I will have progressive muscle weakness.
- B. I will lose strength in my arms.
- C. My children are at greater risk to develop this disease.
- D. I need to remain active for as long as possible.
Correct Answer: C
Rationale: There is no known cause for ALS, and no reason to suspect genetic inheritance. ALS usually begins with muscle weakness of the arms and progresses. The client is encouraged to remain active for as long as possible to prevent respiratory complications.
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The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
- A. Increased intracranial pressure
- B. Decreased intracranial pressure
- C. Hypervolemia
- D. Hypovolemia
Correct Answer: A
Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue.
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 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.
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.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?
- A. An absence seizure
- B. A myoclonic seizure
- C. A partial seizure
- D. A tonic-clonic seizure
Correct Answer: A
Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.