Our Lady of Fatima University

Quezon City

NCMB 316 LECTURE & RLE

CARE OF CLIENTS WITH

PROBLEMS IN NUTRITIONAL
& GASTROINTESTINAL
METABOLISM & ENDOCRINE,
PRECEPTION &
COORDIANTION

(ACUTE & CHRONIC)

Step Five

Rose Ann C. Lacuarin

Academician Head
 MIDTERMS

Week 9

The Nervous System

Week 7

Adrenal Gland Disorders

Week 10

Assessment of Neurologic
Functions and Diagnostic Tests

Week 8

Parathyroid Gland Disorders

Week 11

Degenerative Disease

Rose Ann C. Lacuarin

Academician Head
 Week 7
ADRENAL GLAND DISORDERS
Adrenal Medulla
The inner part of the adrenal gland (a
small organ on top of each kidney).
Makes chemicals such as
epinephrine (adrenaline) and
norepinephrine (noradrenaline)
which are involved in sending nerve
signals.
Adrenal Cortex
The outer region and also the largest
part of an adrenal gland. It is divided
into three separate zones: zona
glomerulosa, zona fasciculata and
zona reticularis. Each zone is
responsible for producing specific
hormones
Types of steroid hormones
Glucocorticoids
Have an important influence on
glucose metabolism
The presence of glucocorticoids in
the blood inhibits the release of CRH
from the hypothalamus and also
inhibits ACTH secretion from the
pituitary.
Are administered frequently to inhibit
the inflammatory response to tissue
injury and to suppress allergic
manifestations
Rose Ann C. Lacuarin
Academician Head
Mineralocorticoids
Mineralocorticoids exert their major
effects on electrolyte metabolism.
They act principally on the renal
tubular and GI epithelium to cause
increased sodium ion absorption in
exchange for excretion of
potassium or hydrogen ions.
Adrenal Sex Hormones (Androgens)
Steroid hormones produced by the
adrenal cortex, exert effects similar
to those of male sex hormones.
May also secrete small amounts of
some estrogens, or female sex
hormones.
When secreted in normal amounts,
the adrenal androgens probably
have little effect, but when
secreted in excess, as in certain
inborn enzyme deficiencies,
masculinization may result. This is
termed the adrenogenital
syndrome.
PHEOCHROMOCYTOMA
Is a rare, usually noncancerous
(benign) tumor that develops in an
adrenal gland.
Usually, a pheochromocytoma
develops in only one adrenal gland.
But tumors can develop in both.
Clinical Manifestations
Triad of symptoms is headache,
diaphoresis, and palpitations
Hypertension
 Week 7
Diagnostic Tests Changes occur in mood and
mental activity; psychosis may
Measurements of urine and plasma levels develop and distress and
of catecholamines and metanephrine. depression are common.
Clonidine suppression test
Diagnostic Tests
Imaging test such as CT and MRI scans,
ultrasound, 131I-metaiodobenzylguanidine Overnight dexamethasone
[MIBG] scintigraphy) suppression test to measure
plasma cortisol level (stress,
obesity, depression, and
Management medications may falsely elevate
results).
Bed rest with the head of the bed elevated
is recommended. Laboratory studies (eg, serum
sodium, blood glucose, serum
Treatment is surgical removal of the potassium, plasma, urinary); 24-
tumor, usually with adrenalectomy hour urinary free cortisol level.
(hypertension usually subsides with
treatment). CT, ultrasound, or MRI scan or
ultrasound may localize adrenal
Monitor ECG changes, arterial pressures, tissue and detect adrenal tumors.
fluid and electrolyte balance, and blood
glucose levels.
Management
CUSHING'S SYNDROME
1. Restrict fluid
Is a disorder that occurs when your body 2. Restrict sodium
makes too much of the hormone cortisol 3. Increase Potassium
over a long period of time. 4. Diet low fat, low cholesterol, low
Cortisol is sometimes called the “stress sugar, low sodium, high k
hormone” because it helps your body 5. Monitor I&O
respond to stress. 6. Weigh patient daily
Cortisol also helps. maintain blood 7. Provide rest
pressure. 8. Promote safety
9. Drug therapy --> Mithothane
ETIOLOGY: Gluthetemide
1. Tumor 10. Manage the tumor --> surgery
2. Hyperplasia of the adrenal glands bilateral adrenalectomy
3. Overused of steroids 11. Gradual withdrawal of steroids

Clinical Manifestations ADDISON'S DISEASE

(Adrenocortical Insufficiency)
“Moon-faced” appearance, oiliness of
skin and acne.
Adrenal insufficiency hyposecretion
Arrested growth, weight gain and of adrenal cortex hormone
obesity, musculoskeletal changes, and
glucose intolerance. ETIOLOGY:
Classic features: central-type obesity, 1. Idiophatic
with a fatty “buffalo hump” in the neck 2. Adrenalectomy
and supraclavicular areas, a heavy trunk
3. Sudden withdrawal of steroids
Relatively thin extremities; skin is thin,
fragile, easily traumatized, with
ecchymoses and striae.

Rose Ann C. Lacuarin

Academician Head
 Week 8
Stress of surgery or dehydration from
Clinical Manifestations
preparation for diagnostic tests or
Muscle weakness surgery may precipitate addisonian
Anorexia or hypotensive crisis.
GI symptoms
Fatigue PARATHYROID GLAND DISORDERS
Emaciation
Dark pigmentation of the skin and HYPERPARATHYROIDISM
mucous membranes
Hypotension caused by overproduction of
parathormone by the parathyroid
Low blood glucose
glands, is characterized by bone
Low serum sodium
decalcification and the
High serum potassium.
development of renal calculi
(kidney stones) containing calcium.
Diagnostic Tests

Aldosterone, Androgen, Cortisol Clinical Manifestations

ACTH
--> All these signs and symptoms are
MRI
attributable to the increased
concentration of calcium in the blood.
Management
Apathy
1. Maintain fluid balance Fatigue
2. Increase fluid intake - oral/IVF Muscle weakness
3. Monitor I&O Nausea
4. Weight patient Vomiting
5. Provide res Constipation
6. Promote safety Hypertension
7. Manage the cause Cardiac dysrhythmias
8. Replace hormones Diagnostic Tests
ALDOSTERONE - Fludrocortisone
CORTISOL - Prednisone Blood tests
ANDROGEN - Testosterone Bone mineral density test
Urine test
Imaging tests of kidneys
Addisonian Crisis
Sestamibi parathyroid scan
Ultrasound
Cyanosis and classic signs of circulatory
shock: pallor, apprehension, rapid and Management
weak pulse, rapid respirations, and low
Surgical removal of abnormal
blood pressure.
parathyroid tissue.
Headache, nausea, abdominal pain, Hydration Therapy
diarrhea, confusion, and restlessness. Mobility -walking or use of a rocking
chair for those with limited mobility
Slight overexertion, exposure to cold,
Avoid a diet with restricted or excess
acute infections, or a decrease in salt
calcium
intake may lead to circulatory collapse,
shock, and death.
Complications: Hypercalcemic Crisis

Rose Ann C. Lacuarin

Academician Head
 Week 8
HYPOPARATHYROIDISM Management

An uncommon condition in which your Watch for early signs of

body produces abnormally low levels hypocalcemia and anticipating
of parathyroid hormone (PTH). signs of tetany, seizures, and
respiratory difficulties.
Clinical Manifestations
Calcium gluconate is kept at the
Irritability of the neuromuscular system bedside with equipment necessary for
emergency IV administration
Numbness
Tingling and cramps in the extremities
The patient complains of stiffness in the
hands and feet.
Overt tetany: bronchospasm, laryngeal
spasm, carpopedal spasm, dysphagia,
photophobia, cardiac dysrhythmias, and
seizures.
Other symptoms: anxiety, irritability,
depression, and delirium. ECG changes and
hypotension may also occur.

Diagnostic Tests

Blood tests
These findings on blood tests might
indicate hypoparathyroidism:

1. A low blood-calcium level

2. A low parathyroid hormone level
3. A high blood-phosphorus level
4. A low blood-magnesium level

A positive Trousseau’s sign or a positive

Chvostek’s sign suggests latent tetany

Rose Ann C. Lacuarin

Academician Head
 Week 9
ANATOMY & PHYSIOLOGY OF THE
NERVOUS SYSTEM

The nervous system consists of 2

major parts:

Central nervous Peripheral nervous

system (CNS) system

1. Brain 1. Cranial Nerves

Frontal
The largest lobe, located in the
2. Spinal Cord 2. Spinal Nerves front of the brain.
The major functions of this lobe are
concentration, abstract thought,
3. Autonomic information storage or memory, and

motor function.
Nervous System
It contains Broca’s area, which is
located in the left hemisphere and is
The Central Nervous System critical for motor control of speech.
Responsible in large part for a
The Brain person’s affect, judgment,
Is one of the personality, and inhibitions.
largest and most Parietal
complex organs
A predominantly sensory lobe
in the human posterior to the frontal lobe.
body.
This lobe analyzes sensory
It is made up of more than 100 billion information and relays the
nerves that communicate in trillions of interpretation of this information to
connections called synapses. other cortical areas and is essential to
The brain is made up of many a person’s awareness of body
specialized areas that work together. position in space, size and shape
discrimination, and right–left
Cerebrum orientation.

The largest part of the brain. Temporal

The cerebrum initiates and coordinates
movement and regulates temperature.
Other areas of the cerebrum enable
speech, judgment, thinking and
reasoning, problem-solving, emotions
and learning.
Other functions relate to vision, hearing,
touch and other senses
Located inferior, this lobe contains the
auditory receptive areas and plays a
role in memory of sound and
understanding of language and music.
Occipital
Located posterior to the parietal lobe,
this lobe is responsible for visual
interpretation and memory.

Rose Ann C. Lacuarin

Academician Head
 Week 9
Brain Stem

consists of the midbrain, pons, and

medulla oblongata.

Structures protecting the brain

Midbrain
Also called mesencephalon
The midbrain serves important functions
in motor movement, particularly
movements of the eye, and in auditory
and visual processing
Pons
The pons relays information about
motor function, sensation, eye
movement, hearing, taste, and more

Medulla Oblongata
plays a critical role in transmitting Dura mater
signals between the spinal cord and the The outermost layer; covers the
higher parts of the brain and in brain and the spinal cord.
controlling autonomic activities, such as
It is tough, thick, inelastic,
heartbeat and respiration.
fibrous, and gray.
When excess pressure occurs in
Cerebrum (2) the cranial cavity, brain tissue may
Medulla Oblongata
CN 1 - OLFACTORY be compressed against these
(4)
CN 2 - OPTIC dural folds or displaced around
CN 9 - them or downward, a process
GLOSSOPHARYNGEAL called herniation.
CN 10 - VAGUS
Midbrain (2) A potential space exists be-
CN 11 - ACCESSORY tween the dura and the skull,
CN 3 - OCULOMOTOR
CN 12 - HYPOGLOSSAL and between the perios- teum
CN 4 - TROCHLEAR
and the dura in the vertebral
column, known as the epidural
space.
Pons (4)
CN 5 - TRIGEMINAL Another potential space, the
CN 6 - ABDUCENS subdural space, also exists below
the dura. Blood or an abscess can
CN 7 - FACIAL
accumulate in these potential
CN 8- VESTIBULOCOCHLEAR spaces.

Rose Ann C. Lacuarin

Academician Head
 Week 9
Arachnoid
The middle membrane; an extremely
thin, delicate membrane that closely
resembles a spider web (hence the
name arachnoid).
The arachnoid membrane has
cerebrospinal fluid (CSF) in the space
below it, called the subarachnoid
space.
This membrane has unique fingerlike
projections, called arachnoid villi, that
absorb CSF into the venous system.
When blood or bacteria enter the
subarachnoid space, the villi become
obstructed and communicating
hydrocephalus (increased size of
ventricles) may result.

Pia mater
The innermost, thin, transparent layer
that hugs the brain closely and
extends into every fold of the brain’s
surface.

The arterial supply of the brain comes

Cerebrospinal Fluid chiefly from 2 main sources:

Is a clear, colorless body fluid found within 1. Vertebro basilar system.

the tissue that surrounds the brain and 2. Internal carotid system.
spinal cord of all vertebrates. 500ml/day
Vertebro-basilar system: it consists of:
CSF is produced by specialised ependymal
cells in the choroid plexus of the ventricles of 4th part of vertebral artery (two)
the brain, and absorbed in the arachnoid ORIGIN: The vertebral artery arises in the
granulations. neck from 1st part of the subclavian
artery.
CSF assists the brain by providing
protection, nourishment, and waste removal. Basilar artery (single)
CSF provides hydromechanical protection of ORIGIN: At the lower border of pons by
the neuroaxis through two mechanisms: the union of the 2 vertebral arteries.
acts as a shock absorber & cushioning the
Posterior cerebral artery (two)
brain against the skull.
ORIGIN: The 2 posterior cerebral arteries
Cerebral Circulation begin at the upper border of the pons as
the 2 terminal branches of the basilar
Is the blood supply to the brain in a given artery.
period of time.
In an adult, CBF is typically 750 millilitres
per minute or 15% of the cardiac output.
This equates to an average perfusion of
50 to 54 millilitres of blood per 100 grams
of brain tissue per minute.

Rose Ann C. Lacuarin

Academician Head
 Week 9
Carotid system
It consists of the intracranial part of the
internal carotid artery and its two
terminal branches; (the anterior and
middle cerebral) arteries.

1. Internal carotid artery (intracranial part)

2. Anterior cerebral artery
3. Middle cerebral artery
4. Cortical branches of the cerebral
arteries
5. Circulus arteriosus (Circle of Willis)

Blood–Brain Barrier

Is the specialized system of brain

microvascular endothelial cells
(BMVEC) that shields the brain from
toxic substances in the blood, supplies
brain tissues with nutrients, and filters
harmful compounds from the brain
back to the bloodstream.

The Spinal Cord

Is a long, tube-like band of

tissue. It connects your brain to
your lower back. Your spinal
cord carries nerve signals from
your brain to your body and
vice versa. These nerve signals
help you feel sensations and
move your body.

The Spinal Tracts

The tracts are responsible for carrying
sensory and motor stimuli to and from
the periphery (respectively).

Vertebral Column
is protection of the spinal cord; it also
provides stiffening for the body and
attachment for the pectoral and pelvic
girdles and many muscles.

Rose Ann C. Lacuarin

Academician Head
 Week 10
Assessment of Neurologic Function;
Diagnostic Tests;
Neurological Disorder: Increased
Intracranial Pressure
INTRACRANIAL PRESSURE
Pressure that exerted by the
cranial contents against the skill
Normal = 10 to 20 mmHh (not more
than 20mmHg)
ROLES OF NURSES IN INCREASE ICP
To identify patients at risk
Cranial contents
A. Brain - cerebral edema, brain tumor
B. CSF - hydrocephalus
C. Blood - bleeding
Example: CVA, TBI, Brain tumor, CNS
Infection, Hemmorrhagic stroke

CRANIAL CONTENTS
To identify s/sx of increased ICP

A. Early s/sx
Altered LOC = restless, confusion,
disorientation, headached, diziness,
vomiting, seizure, changes in speech,
papilledema = swelling of the optic
disc

B. Late s/sx
Pupillary changes - III
Impaired EOM Movement - III,IV,VI
Decerebrate
CPP - Cerebral perfusion pressure Decorticate
normal = 70-100 mmHg Flaccid
MAP - Mean arterial pressure Vomiting
normal = 60-100 mmHg Seizure

MAP = SP+ 2DP

BP - 120/80
MAP - 93mmHg

CPP = MAP - ICP

Munro-Kellie Hypothesis
CPP = 93 - 10
CPP = 83 (Normal)

CPP = 93 - 30
CPP = 63 (decrease)

Rose Ann C. Lacuarin

Academician Head
 Week 10
Reduce brain metabolism
Dislacement of CSF A) lose dose sedative as ordered
150 ml brain 75 ml; spinal cord 75 ml B) manage fever
50 ml brain; 100 ml spinal cord
Transient hyperventilation
Decrease blood volume '
A) dec PCO2 30-40 mmHg
A. Venous blood (unoxygenated) B) vasoconstriction
--> drain venous blood back to the heart
--> position HOB 30-40 degrees - promote Osmotic diuretic ex. Mannitol to relieve
venous drainage cerebral edema

B. ARTERIAL BLOOD (oxygenated) Steroids - anti inflammatory effect ex.

--> dec oxygenated blood Hydrocortisone
--> inc the systolic pressure (widen pulse
pressure)--> to inc MAP Manage the cause

BP = 120/80 MAP = 93
BP = 140/80 MAP = 100 CEREBROVASCULAR ACCIDENT
CPP = 93-30
--> Stroke = brain attack (dec O2 in the
CPP = 63
brain)
CPP = 100-30
CPP = 70 normal
Ischemic stroke
Brain herniation Thrombotic stroke (etio: idiophatic)
RF: Atherosclerosis
--> compress brain tissues (brain stem) -
respiratory center = dec RR
Embolic stroke (etio: thrombus formed
Cardiovascular center = dec HR
in the left side of the heart -> dislodge -
> embolus -> cerebral vesesels ->
CUSHING'S TRIAD
ischemia
1. Increasing systolic pressure
2. Dec RR
Hemorrhagic stroke
3. Dec HR
etio: rupture of blood vessels ->
uncontrolled hpn
--> Abnormal pupil response impaired
EOMs movement herniation -> severe a) cerebral aneurysm
brain injury -> severe inflammation -> inc b) arteriovenous malformation (AV
release of chemical mediators -> malformation)
interleukins -> inc temp
(fever/hyperthermia) ischemia -> injury -> inflammation ->
cerebral edema/bleeding -> diffused
symptoms inc ICP
Management

Position: elevate HOB 30-40 degrees;

low fowlers position to promote venous
WHEN EDEMA/BLEEDING SUBSIDES-
drainage; head and neck should be
aligned, avoid neck flexion and FOCAL SYMPTOMS - S/SX REFERRING
hyperextension. TO A PARTICULAR PART OF THE BRAIN
INVOLVED
Administer O2 - cerebral oxygenation

Rose Ann C. Lacuarin

Academician Head
 Week 10
Focal Symptoms Descriptive Assessment

FRONTAL LOBE - hemiplegia, hemiparesis,

SENSORIUM
broca's aphasia, behavioral changes.
PARIETAL LOBE - sensory deficits
PUPILLARY RESPONSE
TEMPORAL LOBE - wernicke's aphasia,
hearing, taste, smelling, memory
EOMs movement - Doll's
OCCIPITAL LOBE - visual disturbances eye manuever
CEREBELLUM - balance problems and
incoordination RESPIRATION
BASAL GANGLIA - movement disorders,
incoordination, unilateral neglect, apraxia, MOTOR FUNCTION
agnosia and dysarthria

Diffused Symptoms Small vessels = lacunar stroke/infarct

(+) neurologic symptoms -> resolving
--> s/sx inc ICP earliest manifestation - within 24 hours = TIA - transient ischemic
altered LOC attack
--> ASSESS!
A) Descriptive assessment (+) neurologic symptoms -> resolving
B) Scoring system - GCS (glasgow coma beyond 24 hours = RIND - reversible
scale) ischemic neurologic disorder

Nursing diagnosis for focal symptoms

Hemiplegia, hemiparesis = Impaired

mobility/ Risk for complications related to
immobilization/ shortening (contracture)
Aphasia = Ineffective verbal
communication = use picture boards, use
sign language
Dysphagia = Risk for aspiration = position
while = high fowler's/type of food - thick
liquid/ semi solid
Ataxia= Risk for injury/fall = promote
safety
Apraxia = Self care deficit = assist in self
IF THE PATIENT HAS PROBLEM WITH SENSES
care hemiballismus - chorea
DO NOT ADD THE SCORE

Rose Ann C. Lacuarin

Academician Head
 Week 10
Diagnostic test Independent interventions for focal
symptoms
1. CT SCAN
Manage risk factors
2. MRI
Rehabilitation therapy
Management
TRAUMATIC BRAIN INJURY (TBI)
For Thrombotic Stroke
Etiology: trauma Motor vehicle accident,
Manage increase ICP
falls, pedestrian accident, violence
Thrombolytic therapy - to dissolve the
thrombus Mechanisms of injury
--> USA (Urokinase, Streptokinase &
Alteplase
Concussion
Antithrombotic drugs
brain injury -> (+) neuro s/sx -> CT
A) Antiplatelet drugs (Aspirin 30-100 mg od scan or MRI
& Clopidogrel)
B) Anticoagulant drugs (Heparin & Warfarin) Contussion
Independent interventions for focal
brain injury -> hematoma/bruising of
symptoms
the brain tissue
Manage the risk factors close head and open head injury (+)
Rehabilitation therapy infection
(Physiatrist - rehab doctors - MD specialist -
-> REHAB MEDICINE) Skull fracture

For Embolic Stroke Cranial fracture

Basilar skull fracture (base of the
Prevention = filter thrombi left side of the skull)
heart (ex. endocarditis, atrial fibrillation) --> CSF leak - otorrhea & rhinorrhea
Manage increase ICP --> collect fluid and test for glucose

Manage the cause

Bleeding
Independent interventions for focal
Epidural bleeding = between skull and
symptoms
the dura
Manage risk factors --> rupture or middle meningeal artery
Rehabilitation therapy - optimum level of
function TBI - epidural bleeding - "lucid interval" -
>continuous bleeding -> inc ICP ->
For Hemorrhagic Stroke
comatose
Manage increased ICP
Subdural bleeding
Supportive
ACUTE - sudden s/sx
Surgery (Craniotomy) SUBACUTE - s/sx 3 day up to 2 weeks
a) to stop the bleeding CHRONIC - s/sx > 2 weeks
b) to evacuate a large clot

Rose Ann C. Lacuarin

Academician Head
 Week 10
Subarachnoid bleeding - with CSF ICTAL (during) --> observe,type, duration
Intracerebral bleeding - brain tissue 1. turn the head on the side
--> increased ICP!
POST ICTAL (After)
Diagnostic Tests
1. Asleep - assess the breathing pattern
1. CT Scan 2. confused - reorient
2. MRI
3. Skull X-ray
Diagnostic tests

Management 1. Electroencephalogram (EEG ) -most

definitive diagnostic test -->
Manage increase ICP
Epileptogenic focus
Supportive Management
2. CT Scan
Surgery (Craniotomy)
3. MRI
a) to stop bleeding
b) to remove a clot
Management
independent nursing interventions for
focal symptoms Drug therapy - hallmark
Rehabilitation therapy Airway patency
Promote safety
SEIZURE

Abnormal and excessive impulse ANTI SEIZURE DRUGS = CNS DEPRESSANTS

transmission in the brain
Primary - idiophatic -> Primary seizure
disorder = EPILEPSY
Secondary - known causes CVA, TBI,
brain tumor, brain infection, benign
febrile seizure
Generalized tonic clonic seizure
1. Barbiturates (ex. Phenobarbital) = most
sedating
2. Benzodiazephines (ex. Diazepam)
not used for long term treatment

Signs and symptoms sudden withdrawal of drug -> rebound

Motor symptoms = convulsion
Blank staring = petit al/abscence
Atonic (drop attack) - loss muscle tone
Psychomotor = lip smacking
3 phases
seizure
emergency treatment for status
epilepticus (prolonged uncontrolled sz
more than 20 mins that is not relieved
by the usual management
3. Hydantoins (ex. (Phenytoin)

PRE ICTAL (before attack) least sedating = gingival hyperplasia

1. lie down
2. promote safety
3. artificial airway

Rose Ann C. Lacuarin

Academician Head
 Week 11
ABSENCE (petit mal) - Ethosuximide
MYOCLONIC SZ - Valproic acid
PARTIAL SZ - Carbamazepine (Tegretol)
- neuropathic pain = trigeminal
neuralgia
LAMOTRIGINE --> anti seizure/ anti manic
TOPIRAMATE --> anti seizure/ prophylaxis for
migraine
Surgery
1. Cutting the nerve surgically
2. Cutting the nerve with a
radiofrequency probe (using heat) or
a gamma knife
3. Compressing the nerve with a balloon
4. Destroying the nerve by injecting a
drug such as glycerol into it

CRANIAL NERVE DISORDERS

CN V - TRIGEMINAL NEURALGIA

Unilateral facial pain

The cause is usually an abnormally

positioned artery that compresses the
trigeminal nerve.
CN VII - BELL'S PALSY
People have repeated short, lightning-
Unilateral facial paralysis
like bursts of excruciating stabbing pain
in the lower part of the face. The exact cause is unknown.

Symptoms It's believed to be the result of swelling

and inflammation of the nerve that
Pain
controls the muscles on one side of the
Repeated short, lightning-like bursts of
face.
excruciating stabbing pain can be felt in
any part of the lower portion of the face Or it might be a reaction that occurs
but are most often felt in the cheek next after a viral infection.
to the nose or in the jaw
Symptoms
Diagnostic tests
Rapid onset of mild weakness to
1. MRI total paralysis on one side of the
face — occurring within hours to
Treatments days
Facial droop and difficulty making
Antiseizure drugs or other drugs
facial expressions, such as closing
--> antiseizure drug carbamazepine is usually your eye or smiling
tried first Drooling
--> Oxcarbazepine, gabapentin, or phenytoin,
may be prescribed if carbamazepine is
ineffective or has intolerable side effects.

Rose Ann C. Lacuarin

Academician Head
 Week 11
Pain around the jaw or in or behind your Complete Spinal Cord Injury
ear on the affected side
Increased sensitivity to sound on the
affected side C4 Level = SCI
paralysis from the neck and below
Headache
(high tetraplegia/quadriplegia)
A loss of taste
Tetraplegia - paralysis of upper and
Changes in the amount of tears and
lower extremities
saliva you produce

C3 & C4
Diagnostic tests
phrenic nerve = diaphragm
1.There's no specific test for Bell's palsy.
2. Doctor will look at your face and ask you to C6 level
move your facial muscles by closing your SCI = paralysis from the chest below
eyes, lifting your brow, showing your teeth and (low tetraplegia/quadriplegia)
frowning, among other movements.
T6 level
Treatment
SCI - paralysis from the waist below
Patients with Bell's palsy should be treated (high paraplegia = paralysis of both
within three days of the onset of symptoms lower extremities)
with a seven-day course of oral acyclovir
(Zovirax) or valacyclovir (Valtrex), plus a
L1 level
tapering course of oral prednisone
SCI paralysis from the hips below
(low paraplegia)
SPINAL CORD INJURY
bladder dysfunction
bowel dysfunction
Causes:
sexual dysfunction
1. Traumatic -MVA, falls, violence, sport
injuries
2. Non traumatic causes - infections,
tumor

Rose Ann C. Lacuarin

Academician Head
 Week 11
Shock Surgery - laminectomy - post OP ->
move patient as one unit -> log rolling
technique
Is a condition characterized by
Rehabilitation therapy
inadequate tissue perfusion

1. Dec BV -> Dec BP --> hypovolemic Autonomic Dysreflexia

shock/ hemorrhagic shock
2. Dec pumping ability of the heart -> Dec
BP --> cardiogenic shock
3. Massive vasodilation --> pooling blood
downward --> Dec BP --> Circulatory
shock or Distributive shock
Exaggerated autonomic response
due to stimulus (bladder
distension/bowel distension/ any not
necessarily painful within 6 months
after the patient survived spinal
shock

A. Spinal cord injury Management

inc PNS -> vasodilation ->
NEUROGENIC Prevention - bladder and bowel
injury -> inflammation -> SHOCK
training - scheduled time
Position: high fowler's => pooling of
B. Infection
blood downward
inflammation -> vasodilation
Empty the bladder or bowel
-> SEPTIC SHOCK
Antihypertensive drugs as ordered
C. Allergy Anticholinergic drug - atropine
inflammation -> massive vasodilation sulfate
-> ANAPHYLACTIC SHOCK
DEGENERATIVE DISORDERS
Diagnostic tests

1. CT Scan A disease in which the function or

2. Myelography structure of the affected tissues or
organs changes for the worse over
Management time.

Immobilization Is the result of a continuous process

Protect the neck (cervical collar) based on degenerative cell
Massive doses of steroids - changes affecting tissues or organs
methyprednisolone which will increasingly deteriorate
over time whether due to normal
Inc PNS - vasodilation -> vasopressors to
bodily wear or lifestyle choices such
increase HR
as exercise or eating habits
Inc PNS - dec HR (loss of SNS
compensation)
block PNS - anticholinergic drugs ->
atropine sulfate
-> to increase HR

Rose Ann C. Lacuarin

Academician Head
 Week 11
Parkinson's Disease Alzheimer's Disease

Degeneration of the substantia nigra

(midbrain) Degeneration of cells in the cerebral
cortex
ETIO: idiopathic
ETIO: idiophatic
RF: Age, Family Hx, chemical exposure
RF: Age, Family Hx, stress
substantia nigra -> dopamine
producing neuron > basal ganglia A. Precipitation of abnormal protein
called AMYLOID
Neurotransmitters B. Destruction of ACH receptors in the
ACH - excitatory synapses of the brain

DOPA - inhibitory
> cognitive
> emotional
> fine motor
> memory dysfunction
> coordination
> movement disorders

Huntington's Disease Lou Gehrig's Disease

Degeneration of all motor neurons

Degeneration of cells in the cerebral

ETIO: Idiophatic
cortex and basal ganglia

RF: Family hx, male sex

ETIO: Heriditary -> gene (autosomal
> Overexcitation of Neurotransmitter
dominant)
called glutamate -> degeneration of
ALL MOTOR NEURONS UPPER AND
Onset s/sx => middle adult years
LOWER
cerebral cortex

Corticobulbar neurons - cranial

> cognitive
nerves
> emotional
> memory dysfunction
> muscle weakness & paralysis
> movement disorder
> within 5 years die respiratory
paralysis

Rose Ann C. Lacuarin

Academician Head
 Week 11
Parkinson's Disease Diagnostic tests

3 cardinal signs 1. Diagnosis is made by history and

Tremor Physical Examination
Rigidity 2. Initial s/sx - unilateral only
Bradykinesia
Management
Signs and Symptoms
PALLIATIVE!!!
Loss of finger dexterity -> unable to Provide safe and unhurries
button/unbutton; unable to tie shoe environment
laces Prevent aspiration
Microphagia -> small hand writing Assist in self care
loss of postural reflexes Regular exercise
loss of arm swing Independent interventions for specific
freezing movement symptoms
dysphagia Drug therapy

Interventions
GOALS:
Hold something in the hand allow 1. To increase dopamine
patients to eat on their own with the use 2. To decrease ACH
of adaptive utensils
Provide with unhurried environment DRUG THERAPY:
mask like face
Stooping posture 1. Dopaminergic drugs
Shuffling gait - small propulsive steps A) Dopamine precursor
Levodopa --> BBB -> Dopamine (SINEMET)

Adaptive
Utensils
Dopa decarboxylase <-- Carbidopa

B) MAO B Inhibitors
Nursing Diagnosis Monoamine oxidase --> dopamine
ex. Selegilline
1. Risk for Aspiration - position upright, give
them semi solid, thick food Amantadine (Symmetrel) - inc the

2. Impaired physical mobility release of dopamine from substantia

3. Risk for fall nigra (anti viral effect)

4. Risk injury Bromocriptine - dopamine agonist

5. Risk for complications
6. Self care deficit

Rose Ann C. Lacuarin

Academician Head
 Week 11
II. Anticholinergic drugs
Management
block ACH
such as benadryl, akineton, cogentin, 1. Provide safe and unhurried environment
2. Provide good nutrition
artane
3. Assist in self care
4. Present reality
Adverse effects:
5. Reorient the patient
1. drying of the mouth
6. Pictures inside the room
2. constipation
7. Keep them busy with simple task
3. urinary retention
8. Independent interventions for specific
4. blurring of vision
symptoms
Alzheimer's Disease 9. Drug therapy

Pathogenesis Huntington's Disease

Amyloid
ETIOLOGY: Heriditary - gene (autosomal
Destruction of ACH receptors
dominant)
onset s/sx - middle adult years
--> Cognitive dysfunction
--> Dementia
Cardinal Signs
--> 3 stages
Dementia
Cognitive dysfunction
1. Stage 1 - INITIAL STAGE - memory loss Emotional disturbance
Movement disorder = CHOREA
(recent) = "lucid intervals"
2. Stage 2 - CONFUSION STAGE - Diagnostic Tests
sundown syndrome, wandering stage,
1. Based on family history
hallucination, delusions, irritable
2. Genetic testing
3. Stage 3 - TERMINAL STAGE - totally
dependent on care givers Management

Provide safe and unhurried environment

Diagnostic Tests Prevent Aspiration
Assist in self care
1. CT Scan/ MRI - Vascular dementia Regular exercises
2. Thyroid function test = hypothyroidism Independent interventions for specific
3. Serum electrolyte levels symptoms
Drug therapy
Nursing Diagnosis A) Antidepressant drugs
B) Antipsychotic drugs
Self care deficit
C) Anticholinergic drugs
Impaired memory
D) Muscle relaxants
Risk for injury/ fall
Disturbed though process

Rose Ann C. Lacuarin

Academician Head
 Week 11
ALS / Lou Gehrig's Disease
Myasthenia Gravis (MG)
Degeneration of all motor neurons
Muscle weakness and paralysis
NMJ - Neuromascular junction
Respiratory muscle paralysis
> destruction of ACH receptors in the
(+) sensory function
NMJ
Corticobulbar neurons - motor neurons
of cranial nerves ETIO: Thymoma, Idiopathic
Dysphagia RF: Viral infection
Problems on movement of the eyeball
> dec impulse transmission from the
Diagnostic tests nerves to the muscle weakness and
paralysis
1. Muscle biopsy
2. Electromyography (EMG) > first = orbicularis oculi => ptosis
3. Nerve conduction test (NCT)

Management Guillain Barre Syndrome (GBS)

Provide safe and unhurried environment
Support respiratory function
a) respiratory care modalities
b) mechanical ventilation
Prevent Aspiration
Passive ROM exercises
Assist in self care
Independent interventions for specific
symptoms
Drug therapy (glutamate ex. Riluzole)
AUTOIMMUNE DISORDERS
PNS - Peripheral nervous system
destruction of myelin sheath covering
the peripheral nerves
> demyelination of the PNS
> Schwann cells are NOT destroyed
ETIO: Idiopathic
RF: Epstein Barr Virus, Cytomegalovirus,
Campylobacter jejuni
Transmission of impulses motor and
sensory

> first = lower extremities => muscle

Autoimmune disease happens when the weakness and numbness and tingling
body's natural defense system can't tell sensation (paresthesia)
the difference between your own cells
> ASCENDING PARALYSIS and loss of
and foreign cells, causing the body to
reflexes
mistakenly attack normal cells.

Viruses --> enter cell --> mimic protein

inside the cell (protein in the myelin
sheath)

Rose Ann C. Lacuarin

Academician Head
 Week 11
Multiple Sclerosis (MS)
CNS - Central Nervous System
Destruction of myelin sheath
covering CNS
Demyelination of the CNS
Oligodendrocytes are DESTROYED!
ETIO: Idiopathic
RF: Viral infection, females, hormonal
factors
Transmission of impulse
> first = optic nerve => visual
disturbances
Myasthenia Gravis
Myasthenia gravis is characterized by
weakness and rapid fatigue of any of
the muscles under your voluntary
control. It's caused by a breakdown in
the normal communication between
nerves and muscles.
There's no cure for myasthenia gravis,
but treatment can help relieve signs
and symptoms. palliative lang
Though this disease can affect people
of any age, it's more common in women
younger than 40 and in men older than
60.
Symptoms
Eye muscles
Drooping of one or both eyelids
(ptosis)
Double vision (diplopia), which may be
horizontal or vertical, and improves or
resolves when one eye is closed
Rose Ann C. Lacuarin
Academician Head
Face and throat muscles
Impair speaking
Speech might sound soft or nasal,
depending on which muscles have been
affected.
Cause difficulty swallowing
Might choke easily, making it difficult to
eat, drink or take pills. In some cases,
liquids you're trying to swallow come out
your nose.
Affect chewing
The muscles used for chewing might tire
halfway through a meal, particularly if
you've been eating something hard to
chew, such as steak.
Change facial expressions
For example, smile might look like a snarl.
Neck and limb muscles
Weakness in neck, arms and legs.
Weakness in your legs can affect how
you walk. Weak neck muscles make it
hard to hold up your head.
Causes
Abnormal immune reaction (antibody-
mediated autoimmune response)
Thymus gland
Factors that can worsen MG
1. Fatigue
2. Illness or infection
3. Surgery
4. Stress
5. Some medications — such as beta
blockers, quinidine gluconate,
quinidine sulfate, quinine
(Qualaquin), phenytoin, certain
anesthetics and some antibiotics
6. Pregnancy
7. Menstrual periods
Complications
Myasthenic crisis
 Week 11
Diagnosis
Neurological examination
1. Reflexes
2. Muscle strength
3. Muscle tone
4. Senses of touch and sight
5. Coordination
6. Balance
Ice pack test
Assessing improvement in ptosis and
diplopia in ocular MG
Blood analysis
A blood test might reveal the
presence of abnormal antibodies
that disrupt the receptor sites where
nerve impulses signal your muscles
to move.
Repetitive nerve stimulation
Doctors send small pulses of electricity
through the electrodes to measure the
nerve's ability to send a signal to your
muscle.
Single-fiber electromyography (EMG)
This test measures the electrical
activity traveling between your brain
and your muscle.
Imaging
CT scan or an MRI to check if there's a
tumor or other abnormality in your
thymus.
Pulmonary function tests
These tests evaluate whether your
condition is affecting your breathing.
Treatment
Cholinesterase inhibitors
Corticosteroids
Immunosuppressants
Surgery
Video-assisted thymectomy
Robot-assisted thymectomy
Rose Ann C. Lacuarin
Academician Head
Guillain Barre Syndrome (GBS)
Is a rare disorder in which body's
immune system attacks your nerves.
Weakness and tingling in your
extremities are usually the first
symptoms.
These sensations can quickly spread,
eventually paralyzing your whole
body. In its most severe form Guillain-
Barre syndrome is a medical
emergency. Most people with the
condition must be hospitalized to
receive treatment.
The exact cause of Guillain-Barre
syndrome is unknown. But two-thirds
of patients report symptoms of an
infection in the six weeks preceding.
These include respiratory or a
gastrointestinal infection or Zika virus.
reversible schwann cells are not destroy
Symptoms
Prickling, pins and needles
sensations in your fingers, toes,
ankles or wrists
Weakness in your legs that spreads
to your upper body
Unsteady walking or inability to walk
or climb stairs
Difficulty with facial movements,
including speaking, chewing or
swallowing
Double vision or inability to move
eyes
Severe pain that may feel achy,
shooting or cramplike and may be
worse at night
Difficulty with bladder control or
bowel function
Rapid heart rate
Low or high blood pressure
Difficulty breathing
 Week 11
Types
Acute inflammatory demyelinating
polyradiculoneuropathy (AIDP)
The most common form in North
America and Europe. The most
common sign of AIDP is muscle
weakness that starts in the lower part
of your body and spreads upward.
Miller Fisher syndrome (MFS)
Paralysis starts in the eyes. MFS is
also associated with unsteady gait.
MFS is less common in the U.S. but
more common in Asia.
Acute motor axonal neuropathy
(AMAN) and acute motor-sensory
axonal neuropathy (AMSAN)
Are less common in the U.S. But AMAN
and AMSAN are more frequent in
China, Japan and Mexico.
Risk factors
Most commonly, infection with
campylobacter, a type of bacteria
often found in undercooked poultry
Influenza virus
Cytomegalovirus
Epstein-Barr virus
Zika virus
Hepatitis A, B, C and E
HIV, the virus that causes AIDS
Mycoplasma pneumonia
Surgery
Trauma
Hodgkin's lymphoma
Rarely, influenza vaccinations or
childhood vaccinations
COVID-19 virus
COVID-19 Johnson & Johnson
vaccine
Diagnosis
1. Spinal tap (lumbar puncture)
2. Electromyography
3. Nerve conduction studies
Rose Ann C. Lacuarin
Academician Head
Treatment
There's no cure for Guillain-Barre
syndrome. But two types of
treatments can speed recovery and
reduce the severity of the illness.
Plasma exchange (plasmapheresis)
The liquid portion of part of your
blood (plasma) is removed and
separated from your blood cells. The
blood cells are then put back into
your body, which manufactures
more plasma to make up for what
was removed. Plasmapheresis may
work by ridding plasma of certain
antibodies that contribute to the
immune system's attack on the
peripheral nerves.
Immunoglobulin therapy
Immunoglobulin containing healthy
antibodies from blood donors is
given through a vein
(intravenously). High doses of
immunoglobulin can block the
damaging antibodies that may
contribute to Guillain-Barre
syndrome.
Multiple Sclerosis
Multiple sclerosis (MS) is a potentially
disabling disease of the brain and
spinal cord (central nervous system).
In MS, the immune system attacks
the protective sheath (myelin) that
covers nerve fibers and causes
communication problems between
your brain and the rest of your body.
Eventually, the disease can cause
permanent damage or deterioration
of the nerves.
 Week 11
Symptoms Treatment

Numbness or weakness in one or more There is no cure for multiple sclerosis.

limbs that typically occurs on one side
of your body at a time, or your legs and
trunk
Electric-shock sensations that occur
with certain neck movements,
especially bending the neck forward
(Lhermitte sign)
Tremor, lack of coordination or
unsteady gait
Partial or complete loss of vision, usually
in one eye at a time, often with pain
during eye movement
Prolonged double vision
Blurry vision
Treatment typically focuses on
speeding recovery from attacks,
slowing the progression of the
disease and managing MS
symptoms
Treatments for MS attacks
Corticosteroids, such as oral
prednisone and intravenous
methylprednisolone, are prescribed
to reduce nerve inflammation.
Plasma exchange (plasmapheresis)
may be used if your symptoms are
new, severe and haven't responded
to steroids.

Treatments for MS signs and symptoms

Slurred speech
Physical therapy
Fatigue
Physical therapy along with the use of
Dizziness a mobility aid when necessary can also
Tingling or pain in parts of your body help manage leg weakness and other
gait problems often associated with
Problems with sexual, bowel and MS.
bladder function
Muscle relaxants
Diagnosis May experience painful or
uncontrollable muscle stiffness or
spasms, particularly in legs.
1. Blood tests
2. Spinal tap (lumbar puncture) Medications to reduce fatigue
3. MRI
Some drugs used to treat depression,
4. Evoked potential tests, which record including selective serotonin reuptake
the electrical signals produced by inhibitors, may be recommended.
your nervous system in response to
stimuli. Medication to increase walking speed

Rose Ann C. Lacuarin

Academician Head
Rose Ann C. Lacuarin
Academician Head
 Quiz
1.A patient with lethargy, nausea, and
reported muscle weakness is given a series
of tests to rule out physical causes. During
these tests it is revealed that plasma
corticotropin is above normal and cortisol
is below normal. Renin is above normal
and aldosterone is below normal. Adrenal
androgens are below normal. Which of the
following clinical conditions would be most
likely to produce this set of signs and
symptoms?
A. Cushing’s Disease
B. Corticotropin-producing tumor
C. Secondary renal insufficiency
D. Congenital adrenal hyperplasia
E. Addison’s Disease
2. Following a unilateral adrenalectomy,
nurse Betty would assess for hyperkalemia
shown by which of the following?
A. Muscle weakness
B. Tremors
C. Diaphoresis
D. Constipation
3. Which of the following patients are MOST
at risk for hypoparathyroidism?
A. A 75 year-old female who is
diabetic and takes Os-Cal daily.
B. A 59 year-old male with a Mg+ level
of 0.9 mg/dL.
C. A 85 year-old female complaining
of flank pain and constipation.
D. A 19 year-old male with a Ca+ level
of 8.9 mg/dL.
4. This medication is used to treat
hyperparathyroidism in patients with
chronic renal failure. It works by mimicking
the role of calcium in the blood and tricks
the parathyroid gland into stop secreting
PTH (parathyroid hormone). Which of the
following medications does this describe
below? A. Calcitonin C. Lasix
B. Fosamax D. Sensipar
Rose Ann C. Lacuarin
Academician Head
5. A clients with Parkinson's disease is
experiencing tremors, rigidity, and
bradykinesia. The nurse anticipates that
the physician will prescribe which
medication to control these symptoms?
A. Phenytoin (Dilantin)
B. Carbidopa-levodopa (Sinemet)
C. Pyridostigmine (Mestinon)
D. Warfarin (Coumadin)
6. A client recovering from a craniotomy
complains of a "runny nose". Which of the
following nursing actions should be
immediately implemented?
A. Notify the physician
B. Provide the client with soft tissues
C. Monitor the client for signs of a cold
D. Tell the client to use soft tissues to
soak up the drainage
7. The nurse is caring for a client who is in
the chronic phase of brain attack (stroke)
and has a right-sided hemiparesis. The
nurse identifies the nursing diagnosis of
Imbalanced Nutrition: less than body
requirements, related to inability to feed
self . Which of the following is a priority
nursing intervention to help improve the
client's nutrition?
A. Assist the client to eat with the left
hand to build strength.
B. Provide a pureed diet that is easy
for the client to swallow.
C. Inform the client that a feeding tube
will be placed if progress is not made
D. Provide a variety of foods on the
meal tray to stimulate the client's
appetite.
 Quiz
8. A client with trigeminal neuralgia asks a
nurse what can be done to minimize the
episodes of pain. The nurse's response is
based on an understanding that the
symptoms can be triggered by:
A. infection or stress
B. Excessive watering of the eyes or nasal
stuffiness
C. Sensations of pressure or extreme
temperature
D. Hypoglycemia and fatigue
9. A client admitted to the hospital with a
subarachnoid hemorrhage has complaints
of severe headache, nuchal rigidity, and
projectile vomiting. The nurse knows lumbar
puncture (LP) would be contraindicated in
this client in which of the following
circumstances?
A. Vomiting continues
B. Intracranial pressure (ICP) is increased
C. The client needs mechanical ventilation
D. Blood is anticipated in the
cerebralspinal fluid (CSF)
10. A client with subdural hematoma was
given mannitol to decrease intracranial
pressure (ICP). Which of the following results
would best show the mannitol was
effective?
A. Urine output increases
B. Pupils are 8 mm and nonreactive
C. Systolic blood pressure remains at
150 mm Hg
D. BUN and creatinine levels return to
normal
11. While cooking, your client couldn't feel the
temperature of a hot oven. Which lobe could
be dysfunctional?
A. Frontal
B. Occipital
C. Parietal
D. Temporal
Rose Ann C. Lacuarin
Academician Head
12. The nurse is teaching a female client
with multiple sclerosis. When teaching
the client how to reduce fatigue, the
nurse should tell the client to:
A. take a hot bath.
B. rest in an air-conditioned room
C. increase the dose of muscle relaxants.
D. avoid naps during the day
13. A male client is having a tonic-clonic
seizures. What should the nurse do first?
A. Elevate the head of the bed.
B. Restrain the client's arms and legs.
C. Place a tongue blade in the client's
mouth.
D. Take measures to prevent injury.
14. A female client with Guillain-Barré
syndrome has paralysis affecting the
respiratory muscles and requires
mechanical ventilation. When the client
asks the nurse about the paralysis, how
should the nurse respond?
A. "You may have difficulty believing
this, but the paralysis caused by this
disease is temporary."
B. "You'll have to accept the fact that
you're permanently paralyzed.
However, you won't have any sensory
loss."
C. "It must be hard to accept the
permanency of your paralysis."
D. "You'll first regain use of your legs
and then your arms."
15. Postoperatively, for placement of a
shunt for hydrocephalus, the nurse
should place a child in which of the
following positions?
A. Elevated 45 degrees in a supine
position
B. Flat and lying on the unoperated side
C. Flat and lying on the operated side
D. Elevated 30 degrees and prone
 Quiz
16. The nurse assesses cranial nerve VII in a
pediatric client by which of the following
techniques?
A. Gently swab the cornea with a sterile
cotton-tipped applicator
B. Hold the eyes open and turn the head
from side to side
C. Place the child's head in the midline
position with the head elevated and
inject ice water into the ear canal
D. Irritate the pharynx with a tongue
depressor or cotton swab
17. The nurse is caring for a patient who
suffered massive head trauma, and
suspected increased intracranial pressure
(ICP) from an automobile accident. Which
cranial nerves are most appropriate to
check at this time?
A. CN I and CN II
B. CN II and CN III
C. CN III and CN IV
D .CN IV and CN V
18. A client arrives in the emergency
department with an ischemic stroke and
receives tissue plasminogen activator (t-
PA) administration. Which is the priority
nursing assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures
19. During the first 24 hours after
thrombolytic therapy for ischemic stroke,
the primary goal is to control the client’s:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature
Rose Ann C. Lacuarin
Academician Head
20. The nurse is caring for the client with
increased intracranial pressure. The
nurse would note which of the following
trends in vital signs if the ICP is rising?
A. Increasing temperature, increasing
pulse, increasing respirations,
decreasing blood pressure.
B. Increasing temperature, decreasing
pulse, decreasing respirations,
increasing blood pressure.
C. Decreasing temperature, decreasing
pulse, increasing respirations,
decreasing blood pressure.
D. Decreasing temperature, increasing
pulse, decreasing respirations,
increasing blood pressure.
21. A client is being treated in the clinic for
an exacerbation of multiple sclerosis. The
nurse would anticipate administering
which drug?
A. Diazepam (Valium)
B. Interferon b1b (Betaseron)
C. Lioresal (Baclofen)
D. Methylprednisolone (Solu-Cortef)
22. A nurse is performing an assessment
on a client who is suspected of having
Myasthenia Gravis (MG). The complaint
made by the client that reflects a
manifestation commonly seen in clients
with this disease is
A. By the end of the day, my eyelids
usually are drooping.
B. I have a great deal of difficulty
getting up after I rest for a while.
C. I perspire more then I ever have in
the past.
D. When I have a cold, I usually have a
strong cough with it.
 Quiz
23. A female client has clear fluid leaking
from the nose following a basilar skull
fracture. The nurse assesses that this is
cerebrospinal fluid if the fluid:
A. Is clear and tests negative for glucose
B. Is grossly bloody in appearance and
has a pH of 6
C. Clumps together on the dressing and
has a pH of 7
D. Separates into concentric rings and test
positive of glucose

24. The nurse is caring for the male client

who begins to experience seizure activity
while in bed. Which of the following
actions by the nurse would be
contraindicated?

A. Loosening restrictive clothing

B. Restraining the client’s limbs
C. Removing the pillow and raising
padded side rails
D. Positioning the client to side. if
possible. with the head flexed forward

25. The nurse is assigned to care for a female

client with complete right-sided hemiparesis.
The nurse plans care knowing that this
condition:

A. The client has complete bilateral

paralysis of the arms and legs.
B. The client has weakness on the right
side of the body. including the face
and tongue.
C. The client has lost the ability to
move the right arm but can walk
independently.
D. The client has lost the ability to
move the right arm but can walk
independently.

Rose Ann C. Lacuarin

Academician Head
 Answers & Rationale
1. E. Addison’s Disease
2. A. Muscle weakness
Muscle weakness, bradycardia,
nausea, diarrhea, and paresthesia of
the hands, feet, tongue, and face are
findings associated with hyperkalemia,
which is transient and results from
transient hypoaldosteronism when the
adenoma is removed. Tremors,
diaphoresis, and constipation aren't
seen in hyperkalemia.
3. B. A 59-year-old male with a Mg+ level
of 0.9 mg/dL.
This patient is experiencing
Hypomagnesemia which is a cause of
Hypoparathyroidism and is most at
risk for developing this condition.
4. D. Sensipar
The description in this question
describes the action of Calcimimetics.
Sensipar is the only Calcmimetic in this
option.
5. B. Carbidopa-levodopa (Sinemet)
Carbidopa-levodopa is an
antiparkinsonian agent and is used to
control symptoms of Parkinson's
disease. Phenytoin is an
anticonvulsant and antidysrhythmic.
Pyridostigmine is a cholinergic
medication often used to treat
myasthenia gravis. Warfarin is an
anticoagulant.
6. A. Notify the physician
If the client has sustained a
craniocerebral injury or is recovering
from a craniotomy, careful observation
of any drainage from the eyes, ears,
nose or traumatic area is critical
because this may indicate leakage of
cerebrospinal fluid. Cerebrospinal fluid
is colorless and generally non-
purulent, and its presence indicates a
serious breach of cranial integrity. Any
suspicious drainage should be
reported to the physician immediately.
Rose Ann C. Lacuarin
Academician Head
7. A. Assist the client to eat with the left
hand to build strength.
The nurse should teach the client to use
both sides of the body to increase
strength and build endurance. Option B
is incorrect; the question does not
mention swallowing difficulty, so there
is no need to puree the food. Option C is
incorrect; that information would come
from the physician. Option D is
incorrect; the problem is not the food
selection but the client's ability to eat
the food independently.
8. C. Sensations of pressure or extreme
temperature
Pain that accompany this neuralgia are
triggered by stimulation of the terminal
branches of the trigeminal nerve.
Symptoms can be triggered by
pressure from washing the face,
brushing the teeth, shaving, eating and
drinking. Symptoms also can be
triggered by thermal stimuli such as a
draft of cold air. The symptoms listed in
the other options do not trigger the
pain.
9. B. Intracranial pressure (ICP) is
increased
Sudden removal of CSF results in
pressures lower in the lumbar area
than the brain and favors herniation of
the brain; therefore, LP is
contraindicated with increased ICP.
Vomiting may be caused by reasons
other than increased ICP; therefore, LP
isn't strictly contraindicated. An LP may
be performed on clients needing
mechanical ventilation. Blood in the
CSF is diagnostic for subarachnoid
hemorrhage and was obtained before
signs and symptoms of ICP.
10. A. Urine output increases
Mannitol promotes osmotic diuresis by
increasing the pressure gradient in the
renal tubes. Fixed and dilated pupils are
symptoms of increased ICP or cranial
nerve damage. No information is given
about abnormal BUN and creatinine
levels or that mannitol is being given for
renal dysfunction or blood pressure
maintenance.
 Answers & Rationale
12. B. rest in an air-conditioned room
Fatigue is a common symptom in clients
with multiple sclerosis. Lowering the body
temperature by resting in an air-
conditioned room may relieve fatigue;
however, extreme cold should be avoided.
A hot bath or shower can increase body
temperature, producing fatigue. Muscle
relaxants, prescribed to reduce spasticity,
can cause drowsiness and fatigue.
Planning for frequent rest periods and
naps can relieve fatigue. Other measures
to reduce fatigue in the client with
multiple sclerosis include treating
depression, using occupational therapy to
learn energy conservation techniques,
and reducing spasticity.
13. D. Take measures to prevent injury.
Protecting the client from injury is the
immediate priority during a seizure.
Elevating the head of the bed would have
no effect on the client's condition or
safety. Restraining the client's arms and
legs could cause injury. Placing a tongue
blade or other object in the client's mouth
could damage the teeth.
14. A. "You may have difficulty believing this,
but the paralysis caused by this disease is
temporary."
The nurse should inform the client that the
paralysis that accompanies Guillain-
Barré syndrome is only temporary. Return
of motor function begins proximally and
extends distally in the legs.
15. B. Flat and lying on the unoperated side
A child who has had a shunt revision for
hydrocephalus should be placed flat in
bed, lying on the unoperated side. The
head-elevated position may cause the
cerebrospinal fluid to drain too quickly
from the ventricles. Lying on the operated
side can cause injury to the shunt, and the
prone position may cause interference
with respiration.
Rose Ann C. Lacuarin
Academician Head
16. A. Gently swab the cornea with a
sterile cotton-tipped applicator
Gently swabbing the cornea with a
sterile cotton-tipped applicator
assesses cranial nerve VII, which
evaluates the corneal reflex. Holding
the eyes open and turning the head
from side to side evaluates cranial
nerves II, IV, and VI and the
oculocephalic reflex. Placing the
child's head in a midline position with
the head elevated prior to injecting
ice water into the ear canal evaluates
cranial nerves III and VIII, or the
oculovestibular reflex. Irritating the
pharynx with a tongue depressor or
cotton swab evaluates cranial nerves
IX and X, or the gag reflex.
17. B. CN II (OPTIC) and CN III
(OCULOMOTOR)
18. A. Time of onset of current stroke
The time of onset of a stroke to t-PA
administration is critical.
Administration within 3 hours has
better outcomes. Tissue plasminogen
activator (tPA) is classified as a
serine protease (enzymes that cleave
peptide bonds in proteins). It is thus
one of the essential components of
the dissolution of blood clots. Its
primary function includes catalyzing
the conversion of plasminogen to
plasmin, the primary enzyme involved
in dissolving blood clots.
19. C. Blood pressure
Controlling the blood pressure is
critical because an intracerebral
hemorrhage is the major adverse
effect of thrombolytic therapy. Blood
pressure should be maintained
according to the physician and is
specific to the client’s ischemic tissue
needs and risks of bleeding from
treatment. Other vital signs are
monitored, but the priority is blood
pressure.
 Answers & Rationale
20. B. Increasing temperature, decreasing
pulse, decreasing respirations, increasing
blood pressure.
A change in vital signs may be a late
sign of increased intracranial pressure.
Trends include increasing temperature
and blood pressure and decreasing
pulse and respirations. Respiratory
irregularities also may arise. Cushing
triad is a clinical syndrome consisting of
hypertension, bradycardia and irregular
respiration and is a sign of impending
brain herniation. This occurs when the
ICP is too high the elevation of blood
pressure is a reflex mechanism to
maintain CPP.
21. B. Interferon b1b (Betaseron)
Drugs used to treat exacerbations in
ambulatory clients include Interferon b1b,
Interferon b1a (Avonex), and glatiramer
acetate (Copaxone). Diazepam and
lioresal could be used to treat spasticity,
while steroids are used for acute
relapses.
22. A. By the end of the day, my eyelids
usually are drooping.
The primary feature of MG is increasing
weakness with sustained muscle
contraction. After a period of rest the
muscles regain their strength. Muscle
weakness is greatest after exertion or at
the end of the day. Ocular
manifestations are most common, with
ptosis or diplopia occurring in a majority
of clients
24. B. Restraining the client’s limbs
The limbs are never restrained
because the strong muscle
contractions could cause the client
harm. If the client is not in bed when
seizure activity begins. the nurse
lowers the client to the floor. if
possible. protects the head from
injury. and moves furniture that may
injure the client. Other aspects of
care are as described for the client
who is in bed. Options A. C. and D:
Nursing actions during a seizure
include providing for privacy.
loosening restrictive clothing.
removing the pillow and raising side
rails in the bed. and placing the
client on one side with the head
flexed forward. if possible. to allow
the tongue to fall forward and
facilitate drainage.
25. B. The client has weakness on the
right side of the body. including the
face and tongue.
Hemiparesis is a weakness of one
side of the body that may occur after
a stroke. Complete hemiparesis is a
weakness of the face and tongue.
arm. and leg on one side. Complete
bilateral paralysis does not occur in
this condition. Options C and D: The
client with right-sided hemiparesis
has weakness of the right arm and
leg and needs assistance with
feeding. bathing. and ambulating.

23. D. Separates into concentric rings and

test positive of glucose
Leakage of cerebrospinal fluid (CSF)
from the ears or nose may accompany
basilar skull fracture. CSF can be
distinguished from other body fluids
because the drainage will separate into
bloody and yellow concentric rings on
dressing material. called a halo sign. The
fluid also tests positive for glucose.

Rose Ann C. Lacuarin

Academician Head