ATI RN
Questions to Ask About the Neurological System Questions
Question 1 of 5
A patient is admitted to the hospital with Guillain-Barré syndrome. She had weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. During the acute phase of the illness, what should the nurse know about Guillain-Barré syndrome?
Correct Answer: A
Rationale: The correct answer is A) The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity. During the acute phase of Guillain-Barré syndrome, patients are at high risk for respiratory compromise due to muscle weakness, particularly affecting the diaphragm. Monitoring these respiratory parameters is crucial for early detection of respiratory distress and the need for interventions such as mechanical ventilation. Option B is incorrect because early treatment with corticosteroids is not recommended for Guillain-Barré syndrome as it can worsen the condition by suppressing the immune response needed for recovery. Option C is incorrect as the most serious complication is paralysis due to ascending muscle weakness, not ascending demyelination. Option D is incorrect because Guillain-Barré syndrome can affect both voluntary and autonomic nervous systems, leading to potential complications like fluctuations in heart rate and blood pressure. In an educational context, understanding the importance of respiratory monitoring in Guillain-Barré syndrome highlights the critical role nurses play in the care of these patients. By closely monitoring respiratory status, nurses can intervene promptly and prevent respiratory failure, ultimately improving patient outcomes.
Question 2 of 5
An older patient is describing increased rigidity in the shoulders, back, and hips. The loss of elasticity in what tissue contributes to this?
Correct Answer: D
Rationale: The correct answer is D) Cartilage. Cartilage is a connective tissue found in joints between bones, providing cushioning and facilitating smooth movement. As a person ages, cartilage can degenerate, leading to increased rigidity and decreased flexibility in the joints. This is a common phenomenon in conditions like osteoarthritis. Option A) Actin and C) Myosin are proteins found in muscle fibers and are involved in muscle contraction, not in the structure of joints or flexibility of tissues. Option B) Fascia is a connective tissue that surrounds muscles and other structures, providing support and protection. While fascia plays a role in movement and flexibility, it is not the primary tissue responsible for the loss of elasticity described in the scenario. Educationally, understanding the role of different tissues in the body is crucial for healthcare professionals in assessing and managing conditions affecting the musculoskeletal system. Recognizing the impact of aging on cartilage and joint health can help in early detection and intervention to improve quality of life for older patients.
Question 3 of 5
When assessing the patient the nurse notices that the patient has footdrop and the foot slaps down on the floor as the patient walks. How does the nurse document this gait?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Steppage gait. A steppage gait is characterized by the foot dropping down due to weakness of the dorsiflexor muscles, resulting in the toes dragging or scraping on the ground and the foot slapping down during the swing phase of the gait cycle. This is commonly seen in individuals with footdrop, a condition where they are unable to lift the front part of the foot. Option A) Ataxic gait is characterized by a wide-based, staggering, unsteady gait often seen in individuals with cerebellar dysfunction. This does not align with the symptoms described in the question. Option B) Spastic gait is characterized by stiff, jerky movements due to increased muscle tone, commonly seen in conditions like cerebral palsy or stroke. This does not fit the description given. Option C) Antalgic gait refers to a gait pattern that is altered due to pain, where the individual avoids putting weight on a specific limb. This is not the case in the scenario described. Understanding different gait patterns is vital for healthcare professionals, especially nurses, as it provides valuable information about a patient's neurological and musculoskeletal status. Recognizing specific gait abnormalities can help in identifying underlying conditions, determining appropriate interventions, and collaborating effectively with the healthcare team.
Question 4 of 5
During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status every 4 hours. What is a cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?
Correct Answer: A
Rationale: In the acute phase of a stroke, the body attempts to increase cerebral blood flow to the affected area to mitigate the damage caused. One way the body does this is by increasing blood pressure, which is why hypertension (Option A) is the correct answer in this scenario. Hypertension helps in maintaining perfusion to the brain by increasing the pressure within the blood vessels, thereby ensuring an adequate supply of oxygen and nutrients to the brain tissue. Regarding the incorrect options: - Fluid overload (Option B) is not a typical response to increase cerebral blood flow. In fact, fluid overload can lead to increased intracranial pressure, which is detrimental in stroke patients. - Cardiac dysrhythmias (Option C) and S3 and S4 heart sounds (Option D) are not directly related to the body's attempt to increase cerebral blood flow during a stroke. These findings may indicate underlying cardiac issues but are not specific to the situation described in the question. Educationally, understanding the physiological responses to a stroke is crucial for nurses caring for stroke patients. Recognizing signs like hypertension as the body's attempt to increase cerebral blood flow can guide appropriate interventions and help prevent further damage to the brain tissue. Regular monitoring and assessment of vital signs and neurological status are essential components of stroke care to ensure timely interventions and optimal patient outcomes.
Question 5 of 5
How do generalized seizures differ from focal seizures?
Correct Answer: D
Rationale: In understanding the differences between generalized and focal seizures, it is crucial to grasp the underlying neurological mechanisms at play. The correct answer, D, states that generalized seizures involve bilateral synchronous epileptic discharges affecting the entire brain at the onset of the seizure. This is accurate as generalized seizures typically involve widespread electrical disturbances that affect both hemispheres simultaneously, leading to loss of consciousness and symmetric motor manifestations. Option A is incorrect as it describes focal seizures, not generalized seizures. Focal seizures originate in a specific area of the brain and may or may not spread to involve the whole brain. Option B is incorrect because some focal seizures can also result in loss of consciousness, especially if they secondarily generalize. Option C is incorrect as it describes the postictal phase, which can occur after both generalized and focal seizures. Educationally, comprehending the distinction between generalized and focal seizures is vital for healthcare professionals, especially in clinical settings. Understanding these differences aids in accurate diagnosis, appropriate management, and patient education. It also helps in differentiating between various types of epilepsy, guiding treatment decisions, and improving patient outcomes through personalized care plans.