WEEKLY 5 QUESTIONS AND ANSWERS 3

1. A nurse is assessing the function of the twelfth cranial nerve (cranial nerve XII) in a client who sustained a brain attack (stroke). To assess the function of this nerve, the nurse asks the client to perform which of the following maneuvers? a. Extend the arms b. Turn the head toward the nurse’s arms c. Extend the tongue d. Focus the eyes on the object held by the nurse 2. A client with myasthenia gravis arrives at the hospital emergency department in suspected crisis. The physician plans to administer endrophonium (Tensilon) to differentiate between myasthenic and cholinergic crisis. The nurse prepares to administer which medication as prescribed if the client is in cholinergic crisis? a. Atropine sulfate b. Mophine sulfate c. Pyridostigmine bromide (Mestinon) d. Isoproterenol (Isuprel)

3. A nurse reviews the physicians orders for a client with Guillain-Barre syndrome. Which order written by the physician should the nurse question? a. Vital signs assess every 2 hours b. Clear liquid diet c. Passive range-of-motion (ROM) d. Bilateral calf measurements 4. A nurse is performing an assessment on a client with the diagnosis of Brown-Sequard syndrome. The nurse would expect to note which of the following assessment findings? a. Ipsilateral paralysis and loss of touch and vibration b. Bilateral loss of pain and temperature sensation c. Contralateral paralysis and loss of touch sensation and vibration d. Complete paraplegia or quadriplegia, depending on the level of injury 5. The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of subdural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? a. “What was the client’s level of consciousness before the injury?” b. “When did the injury occur” c. “Was the client awake and talking after the injury” d. “What medications has the client received since the fall?”

ANSWER AND RATIONALE

1. C To assess the function of the twelfth cranial nerve (hypoglossal), the nurse would assess the client’s ability to extend the tongue. Impairment of the twelfth cranial nerve can occur with a stroke. 2. A Clients with cholinergic crisis have experienced overdosage of medication. Tensilon will exacerbate symptoms in cholinergic crisis to the point at which the client may need to intubation and mechanical ventilation. Intravenous atropine sulphate is used to reverse the effects of these anticholinesterase medications. Morphine sulphate and pyridostigmine bromide would worsen the symptoms of cholinergic crisis. Isoproterenol is not indicated for cholinergic crisis

3. B Clients with Gullain-Barre syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Because clients with GBS are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitory of vital signs are required. Passive ROM exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. 4. A Brown-Sequard syndrome results from hemisection of spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation is lost because these fibers decussate after entering the cord. 5. A Epidural hematomas frequently are characterized by “lucid interval” that lasts for minutes, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.