UNIT Three Content
A patient with Bell's palsy is frustrated because of the inability to close the eyes. What should the nurse explain to this patient? "The eyes will never be able to close completely again." "As muscle tone improves, the eyes will close completely." "You probably need to see a surgeon because your eye won't close." "It's more important for your mouth to function correctly than your eyelid."
"As muscle tone improves, the eyes will close completely." Rationale As muscle tone improves, the patient should practice forcing the eyes to close 3 or 4 times a day for 5 minutes. The eyes will be able to close again. A surgeon is not required because the affected eye won't close at this time. All sensory organs are important. The patient's eye is as important as the mouth.
A patient diagnosed with ascending Guillain-Barré syndrome 2 months ago has experienced improved motor and sensory function in the upper extremities in the past few weeks. The patient asks the nurse why movement and sensation have not improved in the trunk and legs. How does the nurse respond? a. "If the legs and trunk have not improved by now, they probably won't." b. "These symptoms are characteristic of chronic Guillain-Barré syndrome." c. "You may experience recovery of sensation only in the lower extremities." d. "Complete recovery of motor and sensory function may take months to years."
"Complete recovery of motor and sensory function may take months to years." Rationale Recovery from Guillain-Barre syndrome (GBS) occurs in the opposite order that symptoms appeared, so the upper body will recover first, followed by the lower body. Complete recovery may take months to years. Chronic GBS may occur if complete recovery has not occurred after several years.
The nursing instructor asks a nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? "Facial twitching occurs in both disorders." "Difficulty chewing may occur in both disorders." "Both are disorders of the autonomic nervous system." "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."
"Difficulty chewing may occur in both disorders." Rationale Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects facial expressions and chewing. Both are disorders of the cranial nerves. Facial twitching can be a sign of trigeminal neuralgia, whereas Bell's palsy causes a unilateral facial paralysis. Bell's palsy is caused by the herpes simplex virus, unlike trigeminal neuralgia, which is thought to be caused by excessive firing of irritated nerve fibers in the trigeminal nerve.
What should the nurse instruct the patient with systemic lupus erythematosus who is prescribed hydroxychloroquine to prevent an adverse drug effect? "Have frequent eye examinations." "Take the medication before breakfast." "Have frequent checks of your serum electrolyte level." "Use sunblock with sun protection formula (SPF) of at least 30."
"Have frequent eye examinations." Rationale Hydroxychloroquine is an antimalarial agent that is also used for the treatment of systemic lupus erythematosus (SLE). It acts by decreasing absorption of ultraviolet light by the skin, thereby decreasing the formation of skin lesions. The adverse effect of this drug is retinal damage. Therefore, the patient should have frequent eye examinations when taking this medication. Hydroxychloroquine should be taken after meals; it is not necessary to take it before breakfast. Serum electrolyte levels should be monitored in a patient with SLE, but hydroxychloroquine does not have an effect on renal function. Sunblock should be used to protect the exposed skin from sunlight, but this instruction is not applicable for preventing adverse effects during the hydroxychoroquine use.
Which statement by the patient indicates a need for further teaching about self-management of systemic lupus erythematosus? "I will use moisturizers." "I will pat my skin dry after showers." "I will use sunblock with sun protection factor (SPF) 15." "I will wear long sleeves and cover my legs when going out in the sunlight."
"I will use sunblock with sun protection factor (SPF) 15." Rationale Sunblock with SPF of 30 or higher should be used. Sunblock with SPF of 15 is not strong enough to protect the skin from sunlight. Moisturizers should be used to keep the skin moist and should be applied on dry skin areas. Rubbing should be avoided; instead, the skin should be patted dry. Pants or long dresses with long sleeves to protect the skin should be worn when going out in the sunlight.
The nurse is educating the patient with myasthenia gravis (MG) about the importance of taking medications on time. The patient asks why this is so important. What is the nurse's best response? "It promotes absorption." "It will help you remember to take your medication." "It prevents medication side effects and complications." "It will help maintain blood levels and increase muscle strength."
"It will help maintain blood levels and increase muscle strength." Rationale Patients with MG can maintain blood levels and increase muscle strength for activities such as eating when medications are taken on time. Although it may help the patient to remember to take medications by taking them at the same time each day, this is not the priority reason. The timing of medication administration does not prevent side effects or complications, nor does it promote absorption.
The nurse is teaching a patient with trigeminal neuralgia about the prescribed surgery for the disorder. Which statement by the patient indicates effective teaching? "Complications can occur." "It is a major surgical approach." "The cause of the pain will be disrupted." "A special knife is used to cut out the nerve."
"The cause of the pain will be disrupted." Rationale Surgical techniques for trigeminal neuralgia are used to disrupt the pain. Because surgical procedures for trigeminal neuralgia are minor, the complications of major surgery are prevented. Surgical procedures are considered minimally invasive procedures and not major surgery. The Gamma Knife used in surgery for trigeminal neuralgia uses stereotactic radiation to disrupt the nerve impulses and does not cut out the nerve.
A female patient with a migraine headache is prescribed a triptan preparation. What precautionary measure should the patient take while taking the drug? "Use contraception." "Drink grapefruit juice." "Avoid crossing your legs." "Avoid raising your legs above your heart level."
"Use contraception." Rationale Triptan preparations are used to relieve headache and the symptoms associated with migraine. It produces a vasoconstrictive effect by activating the 5-HT (serotonin) receptors on the cranial arteries, the basilar artery, and the blood vessels of the dura mater. This drug intake may not be safe for women who are pregnant, and therefore contraception should be taken along with this drug. The cautions to avoid such as grapefruit juice, crossing legs, and raising legs above the heart level are not associated with triptan preparation.
A patient who experiences migraine headaches is prescribed a beta-adrenergic blocker. Which medication teaching would the nurse provide? "Chest pain is a normal side effect of this medication." "Your health care provider needs to know if you experience fatigue or shortness of breath." "If you experience flushing, tingling, and a hot sensation, contact your health care provider immediately." "If you experience side effects, stop taking the medication immediately."
"Your health care provider needs to know if you experience fatigue or shortness of breath." Rationale Beta-adrenergic blockers may be prescribed to patients with migraine headaches. These drugs can cause fatigue and shortness of breath. The nurse would instruct the patient to report such symptoms to the health care provider as soon as possible. Chest pain is not a normal side effect of the medication, so the patient would be instructed to report this to the health care provider immediately. Flushing, tingling, and a hot sensation are common side effects of triptan drugs, not beta-adrenergic blockers, so this teaching is not necessary. Beta blockers should never be discontinued immediately or there may be rebound migraine or even rebound tachycardia. These medications should be tapered over a period of weeks.
Which assessment finding is most indicative of Guillain-Barré syndrome (GBS)? Pupillary dilation Expressive aphasia Loss of bowel and bladder control A sudden onset of muscle weakness and pain
A sudden onset of muscle weakness and pain Rationale Although features vary, most patients report a sudden onset of muscle weakness and pain. GBS does not affect speech or pupillary dilation. GBS does affect bowel and bladder control and function, but it is not specific to GBS. Sudden-onset muscle weakness and pain are more indicative of GBS.
What is the gastrointestinal sign of systemic lupus erythematosus Ulcers Dysphagia Esophagitis Abdominal pain
Abdominal pain Rationale Abdominal pain, which occurs due to peritoneal involvement, is the gastrointestinal manifestation of systemic lupus erythematosus (SLE). Ulcers, dysphagia, and esophagitis are the gastrointestinal manifestations of systemic sclerosis.
A patient with a history of seizure activity experiences a few seconds of loss of consciousness with blank staring. During the brief episode, the patient also exhibits lip-smacking. The nurse correctly classifies this as which seizure type? Absence Tonic-clonic Simple partial Complex partial
Absence Rationale An absence seizure consists of a brief, 2- to 3-second period of loss of consciousness. During this type of seizure, the patient may smack the lips, flutter the eyes, or pick at clothing. During a tonic-clonic seizure, the patient may seize for more than 30 seconds up to several minutes and experience stiffening and jerking motions. During a simple partial seizure, the patient may experience tonic-clonic movements and the seizure lasts at least 30 seconds. Complex partial seizures cause the patient to lose consciousness for up to 1 to 3 minutes.
What should be the first intervention for a patient with systemic lupus erythematosus (SLE) when there is severe renal involvement? Prepare the patient for plasmapheresis. Administer immunosuppressants and steroids. Prepare the patient for kidney transplantation. Administer high doses of intravenous glucocorticoids.
Administer immunosuppressants and steroids. Rationale Immunosuppressants and steroids are administered as the first choice of therapy when there is severe renal involvement in a patient with SLE. Plasmapheresis is a process of separating plasma from the cells. Patients who do not respond to immunosuppressants and steroid therapy would be scheduled for plasmapheresis. Kidney transplantation might be performed if the patient does not respond to drug therapies. A high dose of intravenous glucocorticoids might be administered if the patient does not respond to immunosuppressant and steroid therapy.
What is the goal of abortive therapy in migraine headaches? Identifying triggers Preventing reoccurrence of migraines Alleviating pain during the aura phase Decreasing pain during the second phase
Alleviating pain during the aura phase Rationale The goal of abortive therapy in migraine headaches is to alleviate pain during the aura phase. Abortive therapy is not meant to identify triggers, prevent reoccurrence, or decrease pain during the second phase.
A patient with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What should the nurse do next? Assess the patient's vital signs. Allow the patient to remain undisturbed. Turn on the lights for a neurologic assessment. Remove the cloth because it can harbor microorganisms.
Allow the patient to remain undisturbed. Rationale At the beginning of a migraine attack, the patient may be able to alleviate pain with analgesics and by lying down in a darkened room with a cool cloth on his or her forehead. If the patient falls asleep, he or she should remain undisturbed until awakening. Assessing the patient's vital signs will disturb the patient unnecessarily. A cool cloth is helpful for the patient with a migraine and does not present enough of a risk that it should be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.
The nurse is preparing a discharge plan for a patient who has been ordered prednisone. What instruction does the nurse give this patient? Avoid crowds and people with infection. Observe for dehydration. Monitor for decreased blood pressure. Increase fluid intake.
Avoid crowds and people with infection. Rationale Prednisone suppresses the immune system and increases the risk for infection or decreased healing, so the patient is asked to avoid crowds. The patient is asked to monitor for fluid retention and changes in renal function. The patient must also monitor for increased blood pressure. The patient should restrict fluid intake to prevent fluid overload.
The patient with restless leg syndrome (RLS) has been prescribed gabapentin. What does the nurse teach the patient about this medication? a. Gabapentin may cause iron and magnesium deficiencies. b. Be careful while driving because it may cause drowsiness. c. Gabapentin is an opioid that may cause respiratory depression. d. Melatonin may be taken to treat insomnia caused by gabapentin.
Be careful while driving because it may cause drowsiness. Rationale Gabapentin is an antiepileptic drug. These drugs are usually taken at bedtime because they can cause daytime sleepiness. Opioids are prescribed for RLS as a last resort. Melatonin may be taken at bedtime for insomnia that is caused by RLS. Correcting iron and magnesium deficiencies can reduce RLS symptoms.
The nurse encourages a ventilated patient with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? Blinking for "yes" or "no" Moving lips to speak Using sign language Using a laptop to write
Blinking for "yes" or "no" Rationale A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated patient with GBS to communicate. Moving the lips is difficult to do around an endotracheal tube and is exhausting for the patient. Sign language is very time-consuming to learn, unless the patient and family already know it. Use of a laptop may prove too challenging for the patient in advanced stages of GBS.
A patient presents to the emergency department with a severe migraine headache. What lab value is consistent with a known trigger for migraine headaches? HCG 0 mlU/mL Potassium of 3.5 mEq/L Blood sugar of 60 mg/dL White blood cell count of 11,000
Blood sugar of 60 mg/dL Rationale A blood sugar of 60 would indicate that the migraine might have come from hypoglycemia. The hCG level indicates that there is no pregnancy, which would not affect migraines. The potassium of 3.5 mEq/L is normal. The elevated white blood cell count would not likely affect migraines.
Why would a patient with Bell's palsy benefit from psychosocial support? Grieving has to occur. Self-concept is harmed. Body image is affected. Support systems are reduced.
Body image is affected. Rationale Patients with Bell's palsy may require psychosocial support because body image is affected. There is no evidence to support that a patient with Bell's palsy has to grieve. Self-concept is not harmed by Bell's palsy. There is no evidence that psychosocial support is needed because the patient has reduced support systems.
Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? a. Demyelination of neurons is a cause of both diseases. b. Both diseases are autoimmune diseases with ocular symptoms. c. Both diseases affect the patient's respiratory status and muscle function. d. Both diseases exhibit exacerbations and remissions of their signs and symptoms.
Both diseases affect the patient's respiratory status and muscle function. Rationale Both GBS and MG affect respiratory status and muscle function. Only MG is an autoimmune disease with ocular symptoms, and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.
A patient has been prescribed timolol for treatment of migraine headaches. What teaching is most important? Checking a pulse Recognizing an aura Taking the medication with food Avoiding NSAIDS with this medication
Checking a pulse Rationale The patient must be taught to check a pulse because it is important for the detection of bradycardia, which can be an adverse effect of timolol. Recognizing an aura is important, as it indicates the onset of a migraine, but it is more important to teach the patient to recognize adverse affects. Timolol does not have to be taken with food. Avoiding NSAIDs is not necessary.
Which factor indicates to the nurse the only similarity between discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE)? Feeling tired and having a temperature that runs about 100° F (37.8° C) during the day Disfiguring and embarrassing rash Peripheral neuropathies and cranial nerve palsies High risk for renal inflammation
Disfiguring and embarrassing rash Rationale Skin lesions are common to SLE and DLE. Fatigue and fever are common only to SLE. Neurologic manifestations and inflammation of the kidneys are common in SLE.
Which cranial nerve does Guillain-Barré syndrome (GBS) most often affect? Facial Vagus Accessory Hypoglossal
Facial Rationale In Guillain-Barré syndrome (GBS) cranial nerve involvement most often affects the facial nerve. The vagus, accessory, and hypoglossal nerves are not identified as being the most often affected in GBS.
The nurse is providing care to a patient who is experiencing difficulty in swallowing, impaired speech, and ascending paralysis. The patient has tested positive for the Epstein-Barr virus. The nurse anticipates that the patient will be diagnosed with what neurological disorder? Bell's palsy Myasthenia gravis Trigeminal neuralgia Guillain-Barré syndrome
Guillain-Barre Syndrome Rationale Epstein-Barr virus is a known cause of Guillain-Barré syndrome. Its clinical manifestations include dysphagia, aphasia, and ascending paralysis. Bell's palsy involves facial paralysis, and the patient may have difficulty swallowing and speaking; however, Epstein-Barr virus infection is not associated with Bell's palsy. Ascending paralysis and Epstein-Barr virus infection do not indicate myasthenia gravis or trigeminal neuralgia.
What is a clinical manifestation of systemic sclerosis? Alopecia Mouth ulcers Hardening of the skin Dry, scaly, raised rash on the face
Hardening of the skin Rationale Systemic sclerosis or scleroderma is characterized by hardening of the skin. Alopecia, mouth ulcers, and a dry, scaly, raised rash on the face are the clinical manifestations of lupus erythematosus.
What medication used in the treatment of lupus erythematosus decreases the risk for skin lesions? Belimumab Azathioprine Methotrexate Hydroxychloroquine
Hydroxychloroquine Rationale Hydroxychloroquine is an anti-malarial medication used to treat lupus erythematosus. It decreases the absorption of ultraviolet light by the skin and thereby decreases the risk for skin lesions. Belimumab is a monoclonal antibody that prevents binding of B lymphocyte stimulator protein to B cell receptor sites, which will decrease B cell proteins. Azathioprine and methotrexate are immunosuppressive medications used to treat renal or central nervous system lupus.
A patient is undergoing plasmapheresis. Which finding is indicative of a complication of the procedure? Hyperkalemia Hypovolemia Hypertension Hyponatremia
Hypovolemia Rationale Plasmapheresis removes the circulating antibodies thought to be responsible for GBS, essentially separating plasma selectively from whole blood; blood cells are then returned to the patient without the plasma. Hypovolemia is a complication of this procedure. Plasmapheresis is associated with hypotension, not hypertension, and hypokalemia rather than hyperkalemia. Sodium levels are unaffected.
Which laboratory result is consistent with the diagnosis of Guillain-Barré syndrome (GBS)? a. Positive rheumatoid factor b. Decreased serum albumin c. Decreased erythrocyte sedimentation rate d. Increased protein in the cerebrospinal fluid
Increased protein in the cerebrospinal fluid Rationale An increase in the cerebrospinal fluid protein level occurs in GBS due to the release of plasma proteins from inflammation and damage to nerve roots. This release does not affect serum protein levels, which remain normal. The rheumatoid factor is not elevated in this disease and the erythrocyte sedimentation rate could rise.
What is the priority nursing intervention for a patient with systemic lupus erythematosus (SLE)? a. Instructing that fatigue may occur b. Instructing the patient on how to protect the skin c. Teaching the patient to monitor the body temperature d. Suggesting that the patient identify support systems and coping strategies
Instructing the patient on how to protect the skin Rationale While caring for a patient with systemic lupus erythematosus (SLE), the nurse should instruct the patient about how to protect the skin. Instructing the patient that fatigue may occur and teaching the patient to monitor his or her body temperature are secondary nursing interventions. The nurse should help the patient to identify coping strategies and support systems that would help functioning in the community; this intervention is not a top priority.
A patient reports hair loss, swelling, and redness of knees to the nurse. The test reports of the patient reveal inflammation of five joints. Which condition does the nurse suspect in the patient? Gout Scleroderma Lupus erythematosus Raynaud's phenomenon
Lupus erythematosus Rationale Alopecia (hair loss), inflammation of the knees, and polyarthritis (inflammation of five or more joints) indicate lupus erythematosus. Gout is a systemic disease characterized by inflammation of joints due to deposition of urate crystals. Scleroderma or systemic sclerosis is characterized by hardening of the skin. Raynaud's phenomenon (a condition where the fingers turn blue, white, or red due to excess stress or cold conditions) is observed in patients with limited cutaneous systemic sclerosis.
What is the priority nursing intervention for a patient with rapidly ascending Guillain-Barré Syndrome (GBS)? Initiate plasmapheresis or IVIG Obtain, order, and administer corticosteroids Assess and document vital signs and fluid status Maintain airway patency and adequate gas exchange
Maintain airway patency and adequate gas exchange Rationale Inability to maintain an airway is a high risk and potentially fatal consequence of rapidly ascending GBS. The priority nursing intervention is to promote airway patency and adequate gas exchange. Plasmapheresis or IVIG are the primary treatment for GBS but the priority nursing intervention is to ensure a patent airway. Corticosteroids are not used unless medically indicated for associated diseases. Assessment and documentation of fluid status and vital signs is important but is not the priority intervention.
A patient who has repeated tonic-clonic seizures has received one dose of lorazepam. The patient is now having a seizure that has lasted 5 minutes. What is the nurse's next action? Request an order for rectal gel. Notify the Rapid Response Team. Administer oxygen by nasal cannula. Stay with the patient and observe and document the seizure.
Notify the Rapid Response Team. Rationale A seizure lasting more than 5 minutes indicates status epilepticus and is a medical emergency. The nurse should notify the Rapid Response Team because intubation may be necessary. Administering oxygen, requesting an order for rectal gel, and documenting the seizure should be performed only after notifying the Rapid Response Team.
What is a cardiovascular manifestation of systemic lupus erythematosus (SLE)? Pericarditis Pleural effusion Interstitial fibrosis Myocardial fibrosis
Pericarditis Rationale Pericarditis is a cardiovascular manifestation of systemic lupus erythematosus (SLE). A pleural effusion is a pulmonary manifestation of systemic lupus erythematosus. Interstitial fibrosis is a pulmonary manifestation of systemic sclerosis. Myocardial fibrosis is a cardiovascular manifestation of systemic sclerosis.
A patient with Guillain-Barré syndrome is intubated and is receiving mechanical ventilation and intravenous fluids. The nurse assesses a heart rate of 80 beats/min, oxygen saturation of 97%, and blood pressure of 82/46 mm Hg. Which action does the nurse perform next? Notify the Rapid Response Team. Place the patient in a supine position. Request an order to administer intravenous atropine. Contact the provider to request increasing the IV fluid rate
Place the patient in a supine position. Rationale Patients with Guillain-Barré syndrome (GBS) who become hypotensive should be placed in a supine position and given IV fluids. Then the provider should be notified and an increase in IV fluids may be ordered. Atropine is given for bradycardia and is not indicated in this situation. The Rapid Response Team is unnecessary since the patient is intubated and relatively hemodynamically stable.
What medication causes transient lupus-like syndrome? Belimumab Procainamide Glucocorticoid Cyclophosphamide
Procainamide Rationale Procainamide causes transient lupus-like syndrome by increasing levels of antinuclear antibodies in the serum. Belimumab is a monoclonal antibody used to treat systemic lupus erythematosus. Glucocorticoid and cyclophosphamide are used to treat lupus erythematosus.
Which phase of Guillain-Barré syndrome (GBS) coincides with axonal regeneration? Acute phase Plateau period Chronic phase Recovery phase
Recovery phase Rationale The recovery phase (gradually over 4 to 6 months, maybe up to 2 years) is thought to coincide with remyelination and axonal regeneration. The acute phase begins with onset of the first symptoms and ends when no further deterioration occurs. The plateau period follows the acute phase before remyelination and axonal regeneration occurs. Some patients do not completely recover and have permanent neurologic deficits, referred to as chronic GBS.
While assessing a patient with systemic lupus erythematosus, the nurse finds that the patient has chest pain. Which is the appropriate nursing intervention? Administering analgesics Providing comfort measures Reporting to the primary health care provider Notifying to primary health care provider as a common observation
Reporting to the primary health care provider Rationale Chest pain in patients with systemic lupus erythematosus occurs as a result of pericarditis, which is a cardiovascular manifestation. The nurse should immediately notify the primary health care provider if the patient complains of chest pain. The nurse should administer analgesics only on the order of the primary health care provider. Providing comfort measures may provide relief, but it is not the appropriate intervention. Chest pain is not a common observation.
While assessing a patient with systemic sclerosis, the nurse finds thickening and hardening of the skin on the fingers. What does the nurse document in the patient's health record? Calcinosis Sclerodactyly Telangiectasia Bilateral carpal tunnel syndrome
Sclerodactyly Rationale Thickening and hardening of skin of the fingers in the patients with systemic sclerosis indicate sclerodactyly. Calcinosis is the deposition of calcium in the skin tissue. Telangiectasia is the dilatation of blood vessels on the skin or surface of an organ. Bilateral carpal tunnel syndrome is a disorder of the hand characterized by tingling, pain, numbness, and weakness.
A patient has continuous seizures for more than 6 minutes. Which term best describes this condition? Acute seizure Chronic seizure Status epilepticus Tonic-clonic seizure
Status Epilepticus Rationale Status epilepticus is an emergency condition where a patient experiences a seizure for more than 5 minutes; this must be dealt with by emergency care. Status epilepticus can be induced by the withdrawal of antiepileptic medications or alcohol, head and cerebral trauma, infection, or metabolic disturbances. Acute seizures happen when a patient experiences seizures with greater intensity, length, or number than the patient's usual seizures. Any patient suffering from any type of seizures is said to have chronic seizures. A tonic-clonic seizure is characterized by stiffening or rigidity of muscles followed by jerky, rhythmic movements of the extremities.
A patient with bipolar disorder who experiences migraines complains of suicidal thoughts. Which medication might the nurse expect the patient to be taking? Midrin Topiramate Almotriptan Isometheptene
Topiramate Rationale Topiramate is an antiepileptic medication used to treat migraines. When taken in dosages of 400 mg/day or more, it can cause suicidal thoughts and tendencies in patients with bipolar disease. Midrin is an isometheptene combination used in the treatment of migraines; it does not cause suicidal thoughts. Almotriptan is a triptan medication used to treat migraines; it does not cause suicidal thoughts. Isometheptene is a nonspecific analgesic that is used in the treatment of migraines; it does not cause suicidal thoughts in patients with bipolar disorder.
Which cranial nerve (CN) is affected by trigeminal neuralgia? V X IV VIII
V Rationale CN V, the trigeminal nerve, is affected by trigeminal neuralgia. CN X is the vagus nerve, CN IV is the trochlear nerve, and CN VIII is the vestibulocochlear nerve.
A patient with a history of migraines will begin therapy with triptan drugs. Which information does the nurse include in patient teaching? Select all that apply. a. "Report chest pain immediately." b. "Female patients should use a form of birth control." c. "Begin the drug therapy as soon as migraine symptoms develop." d. "Flushing and a feeling of being hot are to be expected." e. "Concurrent use of selective serotonin reuptake inhibitors (SSRIs) is recommended." f. "Discoloration of body fluids is to be expected."
a, b, c, d Rationale Migraine drug therapy should begin as soon as symptoms of migraine are noted. Chest pain may indicate angina and should be reported immediately. Triptan drugs may not be safe for pregnant women and some form of contraception should be used. Common side effects to expect are flushing, tingling, and a hot sensation; these annoying sensations tend to subside after the patient's body gets used to the therapy. The concurrent use of SSRI antidepressants with triptan therapy is contraindicated. Discoloration of body fluids does not occur with triptan drugs.
.Which information will the nurse document when a patient has a seizure? Select all that apply. a. How long the seizure lasted b. Description of the seizure c. Sequence of the seizure progression d. Manual blood pressure recordings during the seizure e. Any change in mental status after the seizure
a, b, c, e Rationale Assessments should be observed and documented during a seizure. These include how long the seizure lasted, a description of the seizure, sequence of the seizure progression, and any change in mental status after the seizure. Manual blood pressures should not be taken during the seizure.
The nurse suspects the patient with myasthenia gravis is experiencing a cholinergic crisis when she exhibits which symptoms? Select all that apply. a. Flaccid paralysis b. Abdominal cramps c. Rise in blood pressure d. Bowel and bladder incontinence e. Worsening of symptoms with Tensilon test
a, b, e Rationale Characteristics of a cholinergic crisis include flaccid paralysis, GI symptoms such as cramping, nausea, vomiting, and diarrhea. Worsening of symptoms with the Tensilon test helps confirm diagnosis of cholinergic crises. Rise in blood pressure and bowel and bladder incontinence are characteristics of a myasthenic crisis.
The primary health care provider prescribed methotrexate to a patient with lupus erythematosus. Which instructions should the nurse provide to the patient? Select all that apply. a. "You should avoid crowds." b. "You should avoid people who are sick." c. "You should take the medication after breakfast." d. "You should be aware that signs of infection are a common finding." e. "If you experience any abnormal effects after taking the drug, you should immediately tell your primary care provider."
a, b, e Rationale Methotrexate is an immunosuppressant used to treat lupus erythematosus. Patients on immunosuppressants should stay from infectious conditions, which include sick people and crowds. Any adverse side effects should be reported immediately to the primary health care provider. Natural corticosteroid levels of the body are very low in the morning; therefore, the medication should be taken before breakfast. Early signs of infection are not natural findings and the primary health care provider should be informed.
What should the nurse include in the plan of care for a patient with trigeminal neuralgia? Select all that apply. a. Provide a soft diet. b. Maintain bedrest during bouts of pain. c. Wash the face gently with warm water and soap. d. Instruct that the pain will lessen as the patient ages. e. Encourage completion of routine hygienic activities.
a, c, d Rationale Because the pain associated with trigeminal neuralgia may be aggravated by chewing, a soft diet might be beneficial. Washing the face gently with warm water and soap would likely not precipitate a bout of pain. Encouraging completion of routine hygienic activities supports the patient's basic care needs. The pain may last for weeks or months, and the patient should not be on bedrest during this time. Attack-free periods become shorter as the person ages. Instructing the patient that the pain will be less as the patient ages is incorrect.
What findings are consistent with a migraine headache? Select all that apply. Nausea Bilateral pain Phonophobia Hypertension Throbbing pain
a, c, e Rationale Nausea, phonophobia, and throbbing pain are symptoms of a migraine headache. Pain is usually on one side of the head, not bilateral. Hypertension is not a symptom of migraines.
What factors are suspected to be associated with the development of Guillain-Barré syndrome (GBS)? Select all that apply. a. Pregnancy b. Epstein-Barr viral infection c. Infection with cytomegalovirus d. Infection with Campylobacter jejuni e. Previous injury to the spinal cord (3 years or less) f. Use of selective serotonin reuptake inhibitors (SSRIs)
b, c, d Rationale GBS is associated with bacterial infection, especially infection with Campylobacter jejuni. Influenza, Epstein-Barr, and cytomegalovirus viral infections have also been associated with GBS. There are other anecdotal and case reports from patients with surgery, trauma, and pregnancy who also developed GBS, but numbers are not sufficient to establish a causal relationship. There are also reports of some vaccines increasing the risk for GBS slightly, but epidemiologic evidence is weak.
The nurse is caring for a patient who is hospitalized with a migraine. Which question must be raised by the nurse to understand what aspect of the patient's lifestyle might have contributed to the migraine attack? Select all that apply. a. "Do you eat grapefruit?" b. "Do you ever miss a meal?" c. "Do you include meat in your diet?" d. "Do you avoid drinking plenty of fluids?" e. "Do you drink beer, wine, or any hard liquor?"
b, c, e Rationale There are many risk factors that may aggravate a migraine attack. These may include missing meals and intake of meat and hard liquor such as beer and wine. Eating grapefruits and avoiding drinking plenty of fluids would not have trigger a migraine attack.
The nurse is caring for a patient who is hospitalized with a migraine. Which question must be raised by the nurse to understand what aspect of the patient's lifestyle might have contributed to the migraine attack? SELECT ALL THAT APPLY a."Do you eat grapefruit?" b. "Do you ever miss a meal?" c. "Do you include meat in your diet?" d. "Do you avoid drinking plenty of fluids?" e. "Do you drink beer, wine, or any hard liquor?"
b, c, e, Rationale There are many risk factors that may aggravate a migraine attack. These may include missing meals and intake of meat and hard liquor such as beer and wine. Eating grapefruits and avoiding drinking plenty of fluids would not have trigger a migraine attack.
What manifestations should the nurse expect to assess in a patient with Guillain-Barré syndrome (GBS) experiencing vagus nerve involvement? Select all that apply. a. Weak shoulder shrug b. Tongue deviates to the left c. Heart rate 54 and irregular d. Blood pressure 98/56 mm Hg e. Coughing when swallowing water
c, d Rationale Bradycardia and hypotension are manifestations of autonomic dysfunction associated with a vagus nerve deficit (CN X), which is associated with GBS. Coughing when swallowing water is associated with deficits in cranial nerves V (trigeminal), VII (facial), X (vagus), XI (accessory), and XII (hypoglossal). Weak shoulder shrug is associated with an accessory nerve deficit (CN XI). Tongue deviating to the left is associated with hypoglossal nerve deficit (CN XII).
The nurse is preparing a diet plan for a patient with a history of migraine headaches. Which foods should be excluded from the chart? Select all that apply. Meats Grapefruits Smoked fish Fresh breads Leafy vegetables
meats, smoked fish, fresh breads Rationale There are many food items that trigger a migraine attack. The intake of meat increases the risk of migraine because it is a rich source of nitrates. Fresh breads contain yeast; therefore, patients with migraine should avoid consumption. Smoked fish are also known to be a causative risk for migraine attack. Leafy vegetables and grapefruit would not trigger a migraine attack.
While reviewing the previous medical records of a patient with a "butterfly" rash, the nurse finds that the patient has been on prednisone therapy for 5 years. Which complications are likely to occur in the patient? Select all that apply. Pancreatitis Organ failure Osteonecrosis Muscle atrophy Mesentric arteritis
osteonecrosis, muscle atrophy Rationale A "butterfly" rash is a dry, scaly, raised rash on the face of patients with systemic lupus erythematosus. Prednisone is a corticosteroid whose chronic use results in osteonecrosis. Long-term exposure to corticosteroids results in muscle wasting, which is known as muscle atrophy. Pancreatitis results from arteritis of the pancreatic artery. Organ failure occurs due to vasculitis affecting any major or small vessels. Arteritis of the pancreatic artery will cause mesentric arteritis.
What complication in patients with lupus erythematosus causes organ failure? Serositis Vasculitis Pericarditis Pleural effusions
vasculitis Rationale Vasculitis is the inflammation of the lining of blood vessels, which causes disruption of blood flow and leads to organ failure. Serositis causes abdominal pain. Pericarditis causes chest pain and myocardial ischemia. Pleural effusions cause dyspnea and arterial blood gas abnormalities.
