Question

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of Multiple Sclerosis (MS). Based on your knowledge of early symptoms of MS what nursing interventions would you implement?

Answer 1

Correct Answers:

Fall Risk and grouping of ADL activities.

Rationale :

🔷In early Multiple Sclerosis (MS), patients experience muscle weakness, fatigue, visual disturbances, and impaired coordination, which increase fall risk.

🔷Nursing interventions should include implementing fall precautions such as assistive devices, safe environment setup, and patient teaching.

🔷Grouping ADLs helps conserve energy since fatigue is one of the most common and early symptoms of MS.

🔷Nurses should encourage rest periods between activities to avoid overexertion.

🔷Addressing fall risk and fatigue directly supports safety and independence in daily living.

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Answer 2

Correct Answers:

Client has allergy to iodine or shellfish.

Rationale :

💎Contrast media used in CT scans often contains iodine, which can cause severe allergic reactions in sensitive individuals.

💎A history of iodine or shellfish allergy is a priority finding that must be reported before administering contrast.

💎Failure to identify this risk can result in anaphylaxis, airway compromise, or death.

💎Nurses must assess for allergies and ensure appropriate pre-medication or alternative imaging is considered.

💎This step ensures patient safety during diagnostic procedures.

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Answer 3

Correct Answers:

Turn the client's head to the side to prevent aspiration.

Rationale :

✨During a seizure, the priority intervention is to maintain a patent airway and prevent aspiration of saliva or vomit.

✨Turning the head to the side allows secretions to drain from the mouth safely.

✨Restraining extremities can cause injury, and inserting objects into the mouth is contraindicated.

✨Vital signs are taken after the seizure ends, not during.

✨Positioning for airway protection ensures patient survival and prevents complications.

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Answer 4

Correct Answers:

"Even when my seizures stop, I will take this drug."

Rationale :

🟢Levetiracetam (Keppra) is an anticonvulsant prescribed for seizure prevention and must be taken continuously, even if seizures stop.

🟢Stopping the medication abruptly can cause seizure recurrence or status epilepticus, a life-threatening condition.

🟢The drug does not prevent auras, nor does it prohibit employment.

🟢While hydration is important for general health, it is not the primary teaching point for this drug.

🟢Understanding adherence demonstrates the patient’s readiness to manage epilepsy long-term.

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Answer 5

Correct Answers:

“Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.”

Rationale :

💎Beta blockers such as propranolol are used as prophylactic (preventive) therapy for migraine headaches.

💎They work by stabilizing vascular tone and preventing the vasodilation that triggers migraine pain.

💎The medication must be taken regularly as prescribed, not just when symptoms appear, in order to be effective.

💎Beta blockers also affect the cardiovascular system, lowering heart rate and blood pressure, so clients must be aware of these effects.

💎Teaching emphasizes adherence to therapy to reduce migraine frequency and severity.

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Answer 6

Correct Answers:

Visual disturbances.

Rationale :

💎Visual disturbances, such as flashing lights or blurred vision, are part of the aura phase of a migraine and signal that a migraine is likely to worsen if not addressed.

💎Early recognition allows the nurse to help the client use prescribed medications and nonpharmacologic interventions (e.g., resting in a dark room) before the headache intensifies.

💎Acting quickly during the aura phase can reduce migraine severity and duration.

💎Other symptoms like vertigo, lethargy, or tongue numbness may occur but are not the earliest indicators for intervention.

💎Timely action improves patient comfort and prevents escalation of pain.

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Answer 7

Correct Answers:

Maintain the head of the bed at 30 degrees or greater.

Rationale :

🔷In Parkinson’s disease, clients are at high risk for aspiration due to impaired swallowing, drooling, and weakened muscles.

🔷Elevating the head of the bed helps maintain an open airway and reduces aspiration risk during meals and rest.

🔷This simple intervention is critical to respiratory safety, one of the main priorities in Parkinson’s management.

🔷Airway devices or breathing techniques are not first-line preventive measures in Parkinson’s compared to aspiration precautions.

🔷Maintaining airway safety is a life-preserving nursing intervention for these patients.

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Answer 8

Correct Answers:

Acyclovir
Corticosteroids

Rationale :

Acyclovir

🔷 Bell’s palsy is strongly associated with reactivation of HSV-1 in the geniculate ganglion, leading to inflammation and neuritis of the facial nerve; an antiviral like acyclovir targets this viral replication.

🔷 When begun early (ideally within 72 hours) of symptom onset, antivirals assist recovery by reducing viral load while the nerve heals, especially in moderate–severe or complete palsy.

🔷 Although steroids provide the primary benefit, adding acyclovir (or valacyclovir) can yield an incremental improvement in complete recovery rates and may reduce synkinesis.

🔷 Typical courses are short (about 7 days) and generally well tolerated; dosing is adjusted for renal impairment, supporting safe use in diverse patients.

🔷 This adjunct strategy aligns with evidence-based management: treat the suspected viral trigger while controlling nerve swelling with steroids for optimal functional outcomes.

Corticosteroids

🔷Corticosteroids are first-line therapy because they decrease edema and inflammation within the narrow facial canal, restoring axonal conduction and improving House-Brackmann grades.

🔷Starting promptly (within 72 hours) is critical; early steroids increase the likelihood of full recovery and shorten time to improvement compared with no treatment.

🔷Common regimens (e.g., prednisone ~60–80 mg daily for 5 days with a taper) are short and designed to maximize anti-inflammatory effect while minimizing adverse events.

🔷By reducing nerve compression and ischemia, steroids directly address the pathophysiology of Bell’s palsy, making them the cornerstone of therapy.

🔷Combining steroids with an antiviral is often recommended in more severe presentations to further optimize outcomes, while maintaining attention to eye protection and symptomatic care.

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Answer 9

Correct Answers:

Corneal Integrity

Rationale :

💎In Bell’s palsy, weakness or paralysis of the facial nerve (cranial nerve VII) causes incomplete eyelid closure on the affected side.

💎This leads to impaired blinking and tear distribution, putting the cornea at risk for drying, abrasions, and ulceration.

💎Monitoring corneal integrity is the most critical nursing assessment, because vision loss from untreated corneal damage is a serious, preventable complication of Bell’s palsy.

💎Nursing interventions include artificial tears, protective eyewear, and taping the eye closed at night, all aimed at preserving corneal moisture and preventing exposure keratitis.

💎While vital signs (blood pressure, heart rate) and glucose monitoring may be important in other contexts, they are not directly impacted by Bell’s palsy and are therefore lower priorities.

💎Ongoing assessment of the eye ensures that nerve recovery does not come at the expense of permanent ocular injury, aligning with the nursing goal of safety and prevention of complications.

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Answer 10

Correct Answers:

Corneal Integrity

Rationale :

💎In Bell’s palsy, weakness or paralysis of the facial nerve (cranial nerve VII) causes incomplete eyelid closure on the affected side.

💎This leads to impaired blinking and tear distribution, putting the cornea at risk for drying, abrasions, and ulceration.

💎Monitoring corneal integrity is the most critical nursing assessment, because vision loss from untreated corneal damage is a serious, preventable complication of Bell’s palsy.

💎Nursing interventions include artificial tears, protective eyewear, and taping the eye closed at night, all aimed at preserving corneal moisture and preventing exposure keratitis.

💎While vital signs (blood pressure, heart rate) and glucose monitoring may be important in other contexts, they are not directly impacted by Bell’s palsy and are therefore lower priorities.

💎Ongoing assessment of the eye ensures that nerve recovery does not come at the expense of permanent ocular injury, aligning with the nursing goal of safety and prevention of complications.

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Exam 2, Neuro FA 25

No.

1 :
A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of Multiple Sclerosis (MS). Based on your knowledge of early symptoms of MS what nursing interventions would you implement?

2 :
Which of these clinical findings would be a priority finding for a client scheduled for a CT scan with contrast?

3 :
A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following interventions should the nurse take?

4 :
A client with new-onset epilepsy is prescribed levetiracetam (Keppra). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which client statement indicates that the effectiveness of client education?

5 :
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. What information is most important to include in this client’s teaching?

6 :
A nurse assesses a client who has a history of migraines. Which clinical manifestation would require the nurse to take action to prevent the migraine from worsening?

7 :
Which intervention is the most important to implement for a client with Parkinson's?

8 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

9 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

10 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

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Exam 2, Neuro FA 25

No.

1 : A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of Multiple Sclerosis (MS). Based on your knowledge of early symptoms of MS what nursing interventions would you implement?

2 : Which of these clinical findings would be a priority finding for a client scheduled for a CT scan with contrast?

3 : A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following interventions should the nurse take?

4 : A client with new-onset epilepsy is prescribed levetiracetam (Keppra). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which client statement indicates that the effectiveness of client education?

5 : A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. What information is most important to include in this client’s teaching?

6 : A nurse assesses a client who has a history of migraines. Which clinical manifestation would require the nurse to take action to prevent the migraine from worsening?

7 : Which intervention is the most important to implement for a client with Parkinson's?

8 : John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

9 : John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

10 : John Smith, 42-year-old male. No significant past medical history, generally healthy.

Answer Options

1 :
A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of Multiple Sclerosis (MS). Based on your knowledge of early symptoms of MS what nursing interventions would you implement?

2 :
Which of these clinical findings would be a priority finding for a client scheduled for a CT scan with contrast?

3 :
A nurse enters a client’s room and finds the client on the floor having a seizure. Which of the following interventions should the nurse take?

4 :
A client with new-onset epilepsy is prescribed levetiracetam (Keppra). After teaching the client about this treatment regimen, the nurse assesses the client’s understanding. Which client statement indicates that the effectiveness of client education?

5 :
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. What information is most important to include in this client’s teaching?

6 :
A nurse assesses a client who has a history of migraines. Which clinical manifestation would require the nurse to take action to prevent the migraine from worsening?

7 :
Which intervention is the most important to implement for a client with Parkinson's?

8 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.

9 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.

10 :
John Smith, 42-year-old male. No significant past medical history, generally healthy.