PrepU Ch. 40- Caring for Clients with Neurologic Deficits.docx

PrepU Ch. 40- Caring for Clients with Neurologic Deficits.docx

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Within the rehabilitation hospital where you practice nursing, you have cared for hundreds of clients who have suffered neurologic deficits from various causes, including cerebrovascular accident, closed head injury, etc. All of these clients have experienced which phase of neurologic deficit? Acute Explanation: Neurologic deficits are divided into three phases: acute, recovery, and chronic. Not all clients with a neurologic deficit experience all phases. Some clients have deficits that begin with an acute phase and move into a recovery phase or into a lifelong chronic phase. A client with paralysis is disturbed by spontaneous erections. Which of the following nursing actions may help the client? Explain that it may occur when the bladder is full Explanation: Explain to the client that spontaneous erections may occur when the bladder is full. Spontaneous erections are unpredictable and sometimes circumstantially inconvenient. Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? Multiple sclerosis Explanation: The cause of MS is not known, and the disease affects twice as many women as men. Parkinson 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 client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Renal
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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 patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? Increased intracranial pressure Explanation: Headache, although not always present, is most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor, leading to increased intracranial pressure.
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