Ch 69 NCLEX

d) Multiple sclerosis (MS) Explanation: The cause of MS is not known and the disease affects twice as many women as men. Parkinson's disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.

a) Creutzfeldt-Jakob disease Explanation: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the CNS characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson's disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

a) Facial (VII) Explanation: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

d) Herpes simplex virus (HSV) Explanation: Viral infection is the most common cause of encephalitis. HSV is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but are not the most common cause of acute encephalitis.

d) Providing palliative care Explanation: The vCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although patient isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

d) Mosquito Explanation: Arthropod vectors transmit several types of viruses that cause encephalitis. The primary vector in North America is the mosquito.

d) Sensory disturbance, limb pain, and behavioral changes Explanation: Sensory disturbance, limb pain, and behavioral changes are the initial symptoms of vCJD. Muscle rigidity, memory impairment, and cognitive impairment occur late in the course of vCJD. The other symptoms listed may happen in the later stages of vCJD.

a) Administer diphenhydramine (Benadryl) and acetaminophen (Tylenol) per orders. Explanation: Administration of amphotericin B may cause fever, chills, and body aches. The administration of diphenhydramine (Benadryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects. Monitoring the serum creatinine and BUN levels may alert the nurse to the development of renal insufficiency and the need to address the patient's renal status, but the symptoms listed are not consistent with renal alterations. As the symptoms listed are associated with the administration of amphotericin B, obtaining CSF fluid for culture is not indicated at this time.

a) Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

a) Controlling seizures and increased ICP Explanation: There is no specific medication for arbovirualencephalitis. Medical management is aimed at controlling seizures and increased ICP.

d) Positive Brudzinski sign Explanation: A positive Brudzinski sign occurs when the patient's neck is flexed (after ruling out cervical trauma or injury), and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning's sign occurs when the patient is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.

b) Initiate seizure precautions. Explanation: A frontal lobe brain abscess produces seizures, hemiparesis, and frontal headache; therefore, the nurse should anticipate the need for seizure precautions. Facial weakness and visual disturbances are associated with a temporal lobe abscess. The patient may experiences expressive aphasia related to the abscess, but that does not indicate the need to ensure the patient is NPO.

b) Polymerase chain reaction (PCR) Explanation: The PCR is the standard test for early diagnosis of HSV-1 encephalitis. A lumbar puncture often reveals a high opening pressure and low glucose and high protein levels in CSF samples. EEG is used to diagnose seizures. An MRI is used to detect brain lesions.

a) Pain, b) Spasticity, d) Fatigue, e) Depression, f) Numbness Explanation: The most commonly reported clinical manifestations of MS are pain, fatigue, spasticity, depression, numbness, weakness, difficulty with coordination, and loss of balance. Aphasia is not a commonly reported clinical manifestation.

d) Magnetic resonance imaging (MRI) Explanation: The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

b) Acetylcholine Explanation: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.

b) Ensure atropine is readily available. Explanation: Atropine should be available to control the side effects of Tensilon. The atropine should be available before the administration of Tensilon. Assessing facial weakness and documenting the results occur after the administration of Tensilon; therefore, they are not the priority interventions.

a) "You must avoid stress and extreme fatigue, because these can trigger a relapse." Explanation: Stress, fatigue, and temperature extremes can trigger relapses of MS. The patient should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Patients taking MS medications should take their medications on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque formation on the brain and spinal cord. RRMS is characterized by states of remission and relapses. This description is consistent with primary progressive MS. RRMS is the most common type and many treatments are available.

b) Apply an eye patch to the right eye. Explanation: An eye patch to the affected eye would help the patient with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the patient. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a patient with double vision. Needed items should be placed on the unaffected (left) side.

a) "I will stretch daily as directed by the physical therapist." Explanation: Hot baths are discouraged due to the risk of injury. Patients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Patients should not hurry through the exercise activity as it may increase muscle spasticity.

d) Initiate isolation precautions. Explanation: The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and patients against the spread of the bacteria. Patients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics following the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done following isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

c) Administer prescribed antibiotics. Explanation: A patient with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF lab results, antibiotic therapy should not be delayed waiting for the results. Encouraging PO fluids and preparing for a CT scan are appropriate interventions depending on the patient, but the priority intervention is the early administration of antibiotics.

b) Call the physician and prepare for intubation. Explanation: The progression of Guillain-Barré syndrome leads to neuromuscular respiratory failure in a large portion of the people affected. Changes in vital capacity and negative inspiratory force are usually key indicators to be monitored for early intervention. The nurse should be alert to the earliest signs that a patient may be heading toward respiratory failure. Explaining the progression of the syndrome will not change the potential need for mechanical ventilation due to respiratory failure. Because the respiratory failure is caused by neurologic changes, assessing the lung sounds, although appropriate, is not the highest priority of the patient's complaint. Encouraging the patient to cough will not change the progression of the syndrome.

d) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." Explanation: The survival rate of Guillain-Barré syndrome is approximately 90%. The patient may make a full recovery or suffer from some residual deficits. Telling the parents not to worry is dismissing their feelings and not addressing their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.

a) Assessing respiratory effort Explanation: A patient in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.