Chapter 38

The nurse is planning care for a patient with Guillain-Barré syndrome (GBS). Which intervention will help with neuropathic pain? 1) Administer gabapentin 2) Turn and reposition every two hours 3) Apply sequential compression devices 4) Perform passive range of motion several times a day

1) Administer gabapentin

A patient is experiencing bilateral symmetrical muscle weakness and sensory changes of both feet and legs. What should the nurse expect to assess that determines the presence of Guillain-Barré syndrome (GBS)? 1) Areflexia 2) Hyporeflexia 3) Hyperreflexia 4) Hyperanalgesia

1) Areflexia

A patient with progressively deteriorating lower extremity motor and sensory function is having a lumbar puncture. What finding suggests that this patient has Guillain-Barré syndrome (GBS)? 1) Elevated protein level 2) Elevated glucose level 3) Reduction in white blood cell count 4) Increased number of red blood cells

1) Elevated protein level

The nurse is reading the results of a single-fiber electromyography completed on a patient suspected of having myasthenia gravis. Which information would validate this patient's diagnosis? 1) Increased jitter 2) Nerve compression 3) Increased antibodies 4) Decreased muscle response

1) Increased jitter

The nurse is reviewing discharge instructions for a patient with myasthenia gravis. What should the nurse emphasize regarding medications? 1) Keep extra doses of medication in the car 2) Store extra doses of medication in the refrigerator 3) Take an extra dose of medication before leaving the house 4) Pack prescribed medications in a suitcase before flying on an airplane

1) Keep extra doses of medication in the car

The nurse notes that a patient has been diagnosed with trigeminal neuralgia. What should the nurse expect the patient to be experiencing? 1) Pain 2) Nausea 3) Sensory deficit 4) Motor weakness

1) Pain

During an assessment the nurse suspects that patient should be evaluated for myasthenia gravis. What did the nurse assess to make this clinical determination? Select all that apply. 1) Ptosis 2) Diplopia 3) Abdominal pain 4) Left leg weakness 5) Epigastric burning

1) Ptosis 2) Diplopia

A patient with Guillain-Barré syndrome (GBS) is receiving plasmapheresis. What finding should the nurse identify as being a complication of this treatment? 1) Septicemia 2) Flu-like symptoms 3) Aseptic meningitis 4) Acute renal failure

1) Septicemia

The nurse is caring for a patient with myasthenia gravis. Which assessment should the nurse complete to determine respiratory functioning? 1) Vital capacity 2) Pulse oximetry 3) Auscultate lung sounds 4) Arterial blood gas analysis

1) Vital capacity

A client is diagnosed with myasthenia gravis. What should the nurse explain about this disease process? 1) "Your nerve endings are worn out." 2) "Your body does not recognize the neurotransmitter needed for movement." 3) "Your body does not make enough of the neurotransmitter needed for movement." 4) "Your nerves have lost their protective covering and impulses cannot reach body areas."

2) "Your body does not recognize the neurotransmitter needed for movement."

A patient is being prepared for a tensilon test. What should the nurse ensure is available prior to the beginning of this test? 1) Oxygen 2) Atropine sulfate 3) Intravenous fluids 4) Nasogastric suction

2) Atropine sulfate

The nurse notes that a patient's primary complaint is burning pain on the right side of the face. What should the nurse realize this patient is describing? 1) Referred pain 2) Atypical pain 3) Vascular compression 4) Peripheral neuropathy

2) Atypical pain

A patient with Guillain-Barré syndrome (GBS) loses respiratory function three weeks into the acute phase. When should the nurse expect respiratory function to return in this patient? 1) During the plateau phase 2) Early in the recovery stage 3) At the end of the plateau stage 4) At the end of the recovery stage

2) Early in the recovery stage

A patient with myasthenia gravis is experiencing sweating and pallor. After administering edrophonium (Tensilon), which finding suggests the patient is experiencing a cholinergic crisis? 1) Clear vision 2) Fasciculations 3) Strong hand grasps 4) Equal shoulder shrugs

2) Fasciculations

The nurse is conducting a physical examination on a female patient experiencing trigeminal neuralgia. What observation indicates that the pain is triggered by hygienic practices? 1) Limited talking 2) Hair not combed 3) Wearing tennis shoes 4) Not wearing makeup

2) Hair not combed

A patient is scheduled for surgery to treat trigeminal neuralgia. For which procedure should the nurse explain that a complication resulting in permanent numbness of the facial area might occur? 1) Plasmapheresis 2) Percutaneous rhizotomy 3) Stereotactic radiosurgery 4) Microvascular decompression

2) Percutaneous rhizotomy

A patient with myasthenia gravis has lost 6 kg of weight over the last two months. What should the nurse suggest to improve this patient's nutritional status? 1) Eat three large meals per day 2) Plan medication doses to occur before meals 3) Restrict drinking fluids prior to and during meals 4) Increase the amount of fat and carbohydrates in meals

2) Plan medication doses to occur before meals

The nurse is reviewing orders written for a patient with trigeminal neuralgia. Which medication should the nurse expect to be prescribed for this patient? 1) Cogentin 2) Compazine 3) Carbamazepine 4) Hydrochlorothiazide

3) Carbamazepine

The nurse is concerned that a patient is at risk for trigeminal neuralgia. What information in the patient's medical record did the nurse use to make this clinical decision? 1) Has a BMI of 34 2) Takes birth control pills 3) History of hypertension 4) Works as a computer operator

3) History of hypertension

A patient with Guillain-Barré syndrome (GBS) asks how the illness develops. What should the nurse respond about the pathophysiology of the disorder? 1) "An infection eats away at the nerve endings." 2) "An infection enters the spinal cord and erodes the nerves at the roots." 3) "The nerves are killed by infiltration of your body's white blood cells used to fight an infection." 4) "After an infection your immune system created antibodies that affect the covering of the nerves."

4) "After an infection your immune system created antibodies that affect the covering of the nerves."

A patient seeks treatment for progressively deteriorating motor and sensory function. What question is essential for the nurse to ask when completing this patient's health history? 1) "Have you been around any small children?" 2) "When was the last time you had anything to eat?" 3) "When was the last time you traveled out of the country?" 4) "Have you recently experienced any lung or stomach infections?"

4) "Have you recently experienced any lung or stomach infections?"

A patient with trigeminal neuralgia asks if there are any nonpharmacological strategies to treat the pain. What should the nurse suggest to this patient? 1) Massage 2) Apply heat 3) Apply cold 4) Acupuncture

4) Acupuncture

The nurse notes that a patient with Guillain-Barré syndrome (GBS) sweats profusely. What should the nurse do about this finding? 1) Place on a cooling blanket 2) Notify the health-care provider 3) Monitor body temperature every two hours 4) Change linen and gown and keep comfortable

4) Change linen and gown and keep comfortable

A patient is admitted for diagnosis and treatment of Guillain-Barré syndrome (GBS). What should the nurse expect to assess during the acute stage of this syndrome? Select all that apply. 1) Edema 2) Paralysis 3) Difficulty breathing 4) Urinary incontinence 5) Numbness and tingling

Edema Paralysis Difficulty Breathing Numbness and Tingling

The nurse notes that a patient with myasthenia gravis is experiencing bulbar manifestations. On what should the nurse focus when assessing this patient? Select all that apply. 1) Swallowing 2) Eye opening 3) Blood pressure 4) Tongue movement 5) Head and neck movement

Swallowing Blood Pressure Tongue Movement Head and Neck Movement

The nurse is reviewing orders written for a patient with myasthenia gravis. Which medication order should the nurse question before administering? Select all that apply. 1) Verapamil 2) Furosemide 3) Erythromycin 4) Nicotine patch 5) Warfarin sodium

Verapamil Erythromycin Nicotine Patch