CH 60 EAQ Cranial Nerve Disorders and Polyneuropathis

The nurse is preparing educational materials about Guillain-Barre syndrome (GBS) and Bell's palsy. How is GBS different than Bell's palsy? a. GBS affects cranial nerves. b. GBS is a mononeuropathy. c. GBS is a potentially fatal disorder. d. GBS results in demyelination of the nerve.

ANS: C Guillain-Barre syndrome (GBS) is a rapidly progressing and potentially fatal disorder. Bell's palsy is a benign disorder in which full recovery may occur in three to six months. Both disorders affect cranial nerves. Guillain-Barre syndrome (GBS) also affects the peripheral nervous system and is a polyneuropathy. Bell's palsy is a mononeuropathy. Both disorders may result in demyelination of the involved nerve.

The nurse teaches a community group about tetanus prevention and immunizations. The nurse should instruct the adults to receive a tetanus and diphtheria toxoid booster, then wait how many years until another is received? Record the answer using a whole number.

ANS: 10 years The nurse should teach that adults should receive a tetanus and diphtheria toxoid booster once every 10 years.

A patient presents with an open wound. The nurse reviews the patient's history and determines that a tetanus booster is not necessary. This determination was made because the patient was immunized against tetanus within the past how many years? Record the answer as a whole number.

ANS: 5 years If an open wound occurs and the patient has not been immunized within five years, then the nurse should consult the health care provider. The health care provider can give a tetanus booster to prevent tetanus. If the patient has been immunized within five years, the booster may be unnecessary.

Which discharge instruction should the nurse provide to a patient with trigeminal neuralgia? a. "Eat a diet that is high in protein." b. "Eat low-calorie foods that are easy to chew." c. "Avoid hygiene activities during periods of analgesia." d. "Use a hard-bristled toothbrush to clean dental plaque."

ANS: A Because chewing may precipitate the pain of trigeminal neuralgia, the patient may not eat properly. Therefore, the nurse teaches the patient to eat food that is high in protein. The nurse should teach the patient to eat food that is easy to chew and also high in calorie content. Hygiene activities should be performed when analgesia is at its peak so that the patient does not have pain. Tooth brushing can precipitate pain. Hence, the patient should be advised to use a small, soft-bristle toothbrush for oral hygiene.

The nurse recalls that which surgical therapy for trigeminal neuralgia is a peripheral procedure? a. Glycerol rhizotomy b. Gamma knife radiosurgery c. Microvascular decompression d. Percutaneous radiofrequency rhizotomy

ANS: A Glycerol rhizotomy is a peripheral procedure used for trigeminal neuralgia where glycerol is injected into one or more branches of the trigeminal nerve. The injection of glycerol causes a chemical ablation resulting in loss of pain sensations. Gamma knife radiosurgery is an intracranial technique that uses high doses of radiation focused on the trigeminal nerve root using stereotactic localization. Microvascular decompression is an intracranial procedure in which the artery pressing on the nerve root is lifted up. Percutaneous radio frequency rhizotomy is an intracranial procedure that involves the destruction of sensory fibers by low-voltage current.

The nurse is providing care to a patient with trismus. Which associated condition does the nurse suspect? a. Tetanus b. Botulism c. Neurosyphilis d. Guillain-Barré syndrome

ANS: A Tetanus is an infection of the nervous system that affects the spinal and cranial nerves. It results from a potent neurotoxin released by the anaerobic bacillus Clostridium tetani. Its initial manifestations include stiffness in the jaw (trismus) and signs of infection. Botulism is caused by gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. Its neurologic manifestations include descending paralysis with muscle incoordination and weakness, difficulty swallowing, seizures, and respiratory muscle weakness. Manifestations of neurosyphilis include pain in the legs, ataxia, loss of deep tendon reflexes, and zones of hyperesthesia. Guillain-Barré syndrome is characterized by ascending, symmetric paralysis that usually affects the cranial nerves and the peripheral nervous system.

A patient presents with initial manifestations of tetanus. The nurse expects what assessment finding? a. Stiffness in the jaw b. Rigidity of the abdomen c. Continuous tonic seizures d. Extreme arching of the back

ANS: A The initial manifestations of tetanus include trismus or stiffness in the jaw. As the disease progresses, there is rigidity of the abdomen. In severe cases, continuous tonic seizures may occur, leading to opisthotonus or extreme arching of the back and retraction of the head.

The nurse is presenting information to a group of nursing students about the incidence of trigeminal neuralgia. What is appropriate for the nurse to include? a. It usually affects only one side of the body. b. It occurs more often in men than in women. c. It is a rare cause of nerve pain among Americans. d. It is most common in 20- to 30-year-old individuals.

ANS: A Trigeminal neuralgia is usually unilateral. It affects only one side of the body. It occurs almost twice as often in women as in men. It is the most commonly diagnosed neuralgia or nerve pain among Americans. In most cases it is diagnosed in people aged 40 and older.

While assessing a patient, the health care provider observes that the patient has trismus and suspects the patient has a tetanus infection. How would the nurse describe trismus and its relation to tetanus infection? a. Trismus is stiffness of the jaw and is one of the first manifestations of tetanus. b. Trismus refers to spasms of the laryngeal and respiratory muscles and is one of the last stages of tetanus. c. Trismus causes extreme arching of the back and retraction of the head and is unrelated to tetanus. d. Trismus is the rigidity of neck muscles, back, abdomen, and extremities and is one of the first manifestations of tetanus.

ANS: A Trismus or lockjaw is stiffness of the jaw due to spasms of the surrounding muscles. It is one of the initial and characteristic features of tetanus. Other manifestations of tetanus include spasms of laryngeal and respiratory muscles, which could cause anoxia, and extreme arching of the back and retraction of the head, also called opisthotonos, which are due to spasms of the trunk (back mainly) musculature. As the disease progresses, there is extreme rigidity of neck muscles, back, abdomen, and extremities.

The nurse is caring for a patient with trigeminal neuralgia. What conservative therapies are appropriate to be included on the patient's plan for treatment? Select all that apply. a. Acupuncture b. Vitamin therapy c. Glycerol rhizotomy d. Tricyclic antidepressant e. Microvascular decompression

ANS: A B The collaborative care for trigeminal neuralgia includes drug therapy, conservative therapy, and surgical therapy. Acupuncture and vitamin therapy are conservative therapy modalities used to treat trigeminal neuralgia. Glycerol rhizotomy is a peripheral surgical therapy for trigeminal neuralgia. Tricyclic antidepressants are part of drug therapy for trigeminal neuralgia. Microvascular decompression is an intracranial surgery used to treat trigeminal neuralgia.

A nurse advises a patient with Bell's palsy to use a facial sling. What benefits of the facial sling should the nurse mention that would encourage the patient to use it? Select all that apply. a. It facilitates eating. b. It supports facial muscles. c. It improves mouth alignment. d. It improves cosmetic appearance. e. It immobilizes the face, thereby preventing pain.

ANS: A B C A facial sling may be helpful to support affected muscles, improve lip alignment, and facilitate eating. A facial sling does not improve cosmetic appearance. The sling allows movements of the face.

A nurse is explaining to a patient with Bell's palsy the preventive measures for complications related to the eye. What instructions should the nurse give the patient? Select all that apply. a. Wear dark glasses. b. Tape eyelids at night. c. Check vision regularly. d. Instill artificial tears frequently. e. Keep the room at a moderate temperature.

ANS: A B D One common complication of Bell's palsy is corneal abrasions and infections due to corneal anesthesia. The patient should wear dark glasses for protective and cosmetic reasons. Taping the lids closed at night may be necessary to provide protection. Artificial tears (methylcellulose) should be instilled frequently during the day to prevent drying of the cornea. The sense of vision is not compromised in facial palsy. Keeping the room at a moderate temperature does not help in preventing eye complications; it may help in preventing triggers of trigeminal neuralgia.

The nurse is giving home instructions to a patient recently diagnosed with Bell's palsy. Which comments by the nurse are most appropriate? Select all that apply. a. "It is important to maintain good nutrition." b. "Full recovery generally occurs in 3 to 6 months." c. "Cold packs need to be applied four times a day for 20 minutes each time." d. "Dark glasses will help protect your eyes and help to cover up the paralysis." e. "Chew your food on the same side as the paralysis to prevent the facial muscle from weakening."

ANS: A B D Thorough oral hygiene must be carried out after each meal to prevent development of parotitis, caries, and periodontal disease. Eating nutritionally is important, and dark glasses help to protect the eyes from light and also have a cosmetic effect. Patients with Bell's palsy generally can expect a complete recovery after six months. Hot wet packs are applied to reduce the discomfort. To prevent trapping of food, teach patients to chew food on the unaffected side.

A patient has been admitted to the hospital with Guillain-Barré syndrome with severe autonomic dysfunction. Which of the dysfunctions should the nurse anticipate and monitor for? Select all that apply. a. Dysrhythmias b. Bradycardia c. Tabes dorsalis d. Charcot's joints e. Orthostatic hypotension

ANS: A B E In Guillain-Barré syndrome, autonomic dysfunction is common and usually takes the form of bradycardia and dysrhythmias. Orthostatic hypotension secondary to muscle atony may occur in severe cases. Tabes dorsalis and Charcot's joints do not occur in Guillain-Barré syndrome; these symptoms are characteristics of neurosyphilis. Tabes dorsalis, or progressive locomotor ataxia, is characterized by vague, sharp pains in the legs. Charcot's joints, which are characterized by enlargement, bone destruction, and hypermobility, also occur as a result of joint effusion and edema.

The nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What should be the focus of collaborative care? Select all that apply. a. Control of spasms with diazepam b. Administration of polyvalent antitoxin c. Tracheostomy for mechanical ventilation d. Teaching correct processing of canned foods e. Administration of facial sling to support affected muscles

ANS: A C Control of the spasms of tetanus is essential because the laryngeal and respiratory system spasms cause apnea and anoxia. A tracheostomy is performed early so mechanical ventilation may be done to maintain ventilation. A facial sling may be administered for Bell's palsy. Use of polyvalent antitoxin and teaching the correct canning process is done for botulism.

The nurse is providing teaching to a group of nursing students about the actions of the primary medications used to treat trigeminal neuralgia. What is appropriate for the nurse to include in the education? Select all that apply. a. Lamotrigine blocks the nerve firing. b. Amitriptyline stabilizes the neuronal membrane. c. Nortriptyline can be used to treat constant burning. d. Baclofen is a first-line drug for treating the condition. e. Opioids are highly effective in controlling the nerve pain. f. Analgesics help to control the pain associated with this condition.

ANS: A C Lamotrigine is an antiseizure drug that stabilizes the neuronal membrane and blocks the nerve firing. Nortriptyline is an antidepressant drug and is a second-line choice that can be used to treat constant burning associated with trigeminal neuralgia. Amitriptyline is also a tricyclic antidepressant that treats constant burning or aching pain. Baclofen is not a first-line drug for treating the condition. It may be given along with a first-line antiseizure drug if a single drug is not effective. Opioids and analgesics are usually not effective in controlling the nerve pain of trigeminal neuralgia.

A nurse has to explain to a patient having Bell's palsy the reason why oral hygiene and nutrition are affected in this condition. What points should the nurse emphasize while explaining? Select all that apply. a. The taste sensation is impaired. b. The sensation inside the mouth is affected. c. In Bell's palsy, muscles of mastication are paralyzed. d. There is accumulation of food on one side of the mouth. e. There is pain around the jaw, which prevents the proper chewing of food.

ANS: A D E Bell's palsy is a lower motor neuron facial paralysis of unknown etiology. Malnutrition in Bell's palsy may occur due to inability to chew food and loss of taste sensation because of pain around the jaw. Oral hygiene is affected due to accumulation of food in one side of the mouth. Facial nerves do not supply muscles of mastication; sensation inside the mouth is not affected, because it is carried by the trigeminal nerve.

A nurse is preparing a nursing care plan for a patient with trigeminal neuralgia. What information should the nurse elicit during the patient's health history to aid in planning? Select all that apply. a. Food habits b. Bowel habits c. Bladder habits d. Self-medication to decrease pain e. Frequency of attacks and triggers

ANS: A D E Patients with trigeminal neuralgia are primarily treated on an outpatient basis. Patients with trigeminal neuralgia may have difficulty in chewing; therefore it is important to ask about food habits when planning care. Relevant history for the assessment of the attacks includes the triggering factors, characteristics, frequency, and pain management techniques; these help the nurse to plan for patient care. Trigeminal neuralgia does not affect bladder and bowel function; therefore related history is not needed.

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. What instructions should the nurse give this patient? Select all that apply. a. Avoid eating hot food or beverages. b. Regularly shave using a razor blade. c. Avoid moving the jaw as much as possible. d. Protect the face from extreme temperatures. e. Check oral cavity after eating food for any residual food particles.

ANS: A D E Percutaneous radiofrequency rhizotomy can often result in facial numbness, corneal anesthesia, and trigeminal motor weakness. The nurse should teach the patient to avoid eating hot foods to prevent burns in the mouth and to protect the face from extreme temperatures. Decreased ability to chew and decreased sensation in the mouth may cause deposition of food particles in the mouth, and so the patient should check the oral cavity after eating food. The patient should be encouraged to use electric razors rather than a razor blade for preventing cuts in the face due to the blades. The patient should be encouraged to do jaw movements as much as possible to overcome motor weakness.

The nurse that is caring for a patient with Bell's palsy should monitor for what complications? Select all that apply. a. Weight gain b. Corneal abrasions c. Respiratory failure d. Psychologic withdrawal e. Mucous membrane trauma

ANS: B D E Complications of Bell's palsy include corneal abrasions, psychologic withdrawal, and mucous membrane trauma. Instead of weight gain, the patient may have malnutrition. Respiratory failure is a common complication of Guillain-Barre syndrome (GBS) rather than of Bell's palsy.

The nurse expects a prescription for what treatment to help control a patient's spasms that are caused by tetanus? a. Opioids b. Barbiturates c. Metronidazole d. Tetanus immune globulin

ANS: B Barbiturates cause muscle relaxation and help control the spasms caused by tetanus. Opioids such as morphine or fentanyl are analgesics that help in pain management. Metronidazole is given to inhibit further growth of the bacteria Clostridium tetani. A large dose of tetanus immune globulin is given to a patient with clinical manifestations of tetanus to neutralize the circulating toxins.

Which instruction should be given to a patient who is diagnosed with Bell's palsy? a. Sit upright for meals and follow a thickened liquid high protein diet. b. Prevent corneal drying by instillation of ointment at night with an eye shield. c. Continue prescribed corticosteroid eye drops until the eye can close properly. d. Complete the full course of prescribed antibiotics even if eye drainage is nonpurulent.

ANS: B Because the patient cannot shut the eye, the cornea may become dry, increasing the risk for injury. Using eye ointment with an eye shield at night will protect the cornea. Systemic corticosteroids are prescribed orally to stop the inflammation and are effective if begun within two weeks of the onset of symptoms. The patient is able to swallow, should chew on the unaffected side, and may have some difficulty with drooling. Antibiotics usually are not prescribed because there is no bacterial infection.

The nurse is preparing educational materials about the differences between Bell's palsy and trigeminal neuralgia. What information should the nurse include about Bell's palsy? a. It is more common than trigeminal neuralgia. b. It affects the seventh cranial nerve, whereas trigeminal neuralgia affects the fifth. c. It causes severe pain, whereas trigeminal neuralgia causes drooping of the mouth. d. It can affect any age group, whereas trigeminal neuralgia is mostly seen in children.

ANS: B Bell's palsy affects the facial nerve, which is the seventh cranial nerve. Trigeminal neuralgia affects the trigeminal nerve, which is the fifth cranial nerve. Bell's palsy occurs in nearly 40,000 Americans each year, whereas, trigeminal neuralgia affects approximately 150,000 Americans every year. Trigeminal neuralgia causes severe pain along the distribution of the trigeminal nerve, whereas, Bell's palsy causes drooping of the mouth due to paralysis of the motor branches of the facial nerve. Bell's palsy can affect any age group, but trigeminal neuralgia is mostly seen in middle aged people.

Which noninvasive surgical procedure is often performed in patients with trigeminal neuralgia? a. Glycerol rhizotomy b. Gamma knife radiosurgery c. Microvascular decompression d. Percutaneous radiofrequency rhizotomy

ANS: B Gamma knife radiosurgery is a noninvasive surgical procedure in which high doses of radiation are focused on the trigeminal nerve root using stereotactic localization. Glycerol rhizotomy is a percutaneous procedure in which glycerol is injected into the trigeminal cistern. Microvascular decompression involves lifting the artery pressing on the nerve root in the posterior fossa with a wedge of sponge, leading to a removal of pressure at the nerve root or entry zone. Percutaneous radiofrequency rhizotomy is the destruction of sensory fibers by means of low-voltage current.

A patient, injured at work with an open cut, asks the occupational health nurse whether a "tetanus shot" is needed. The nurse should base the response on which of the following facts? a. Whether the patient had tetanus in the past. b. When the patient last received a tetanus toxoid booster. c. Whether the patient is experiencing any stiffness in the jaw. d. Whether the patient has received antibiotics in the past six weeks.

ANS: B Tetanus is a severe infection resulting from an anaerobic bacterium Clostridium tetani. It has a very high mortality rate and prevention with immunization is the first line of treatment. Adults should receive a tetanus booster every 10 years routinely and receive a booster every five years if an open wound occurs. The nurse should evaluate the patient's medical records to determine if a booster is warranted. Contracting and surviving tetanus are rare. Adequate immunization should prevent the disease so stiffness of the jaws, an early sign of the disease once known as lockjaw, should not occur. Previous treatment with antibiotics is not a factor for determining whether a tetanus booster is indicated.

The nurse reviews a patient's medical record and notes tic douloureux. The nurse expects what assessment finding? a. Severe, bilateral pain along the distribution of the trigeminal nerve b. Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve c. Cycles of pain along the trigeminal nerve and refractoriness that continues for hours d. Specific point along the trigeminal nerve that can initiate pain when it is lightly touched

ANS: B Trigeminal neuralgia is also referred to as tic douloureux. It is characterized by recurrent episodes of stabbing pain along the distribution of the trigeminal nerve. It is not a severe, bilateral pain but a severe, unilateral pain along the distribution of the nerve. Cycles of pain along the trigeminal nerve and refractoriness that continue for hours are referred to as clustering. The specific point along the trigeminal nerve that can initiate pain when it is lightly touched is called a trigger zone.

The nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. What characteristics of Bell's palsy should the nurse include? Select all that apply. a. Facial grimacing b. Unable to whistle c. Flat nasolabial fold d. Unable to open the eyelid e. Frequent tearing of the eye

ANS: B C In Bell's palsy, the muscles innervated by the facial nerve become weak, and the patient is unable to whistle. There is also flattening of the nasolabial fold. The nasolabial folds are commonly known as "smile lines" or "laugh lines." They are the two skin folds that run from each side of the nose to the corners of the mouth. They separate the cheeks from the upper lip. Facial grimacing is a feature of trigeminal neuralgia rather than Bell's palsy. In Bell's palsy, the patient is unable to close the eyelid when closure is attempted. In trigeminal neuralgia, there is frequent tearing of the eye.

The oral intake of a patient with trigeminal neuralgia is sharply reduced, and the patient's nutritional status is compromised. What is the priority nursing intervention? a. Serving lukewarm food b. Ensuring that the food is easy to chew c. Providing food through a nasogastric tube d. Encouraging intake of foods high in protein

ANS: C If the nutritional status of the patient is compromised due to a sharp reduction of oral intake, the priority intervention should be to provide enteral feedings through a nasogastric tube. Once a reasonable amount of nutrition is restored and the patient is able to feed orally, food should be served lukewarm and at frequent intervals. After the patient can eat normally, food should be easy to chew and high in protein content. Until then, nasogastric feedings are indicated to facilitate a return to homeostasis.

A patient is diagnosed with tetanus infection. The nurse has to explain the treatment plan for this patient to the caregivers. What are the interventions that would be a part of the treatment plan? Select all that apply. a. Administration of antiviral drugs b. Administration of opioid analgesics c. Administration of sedatives and muscle relaxants d. Administration of tetanus toxoid and immune globulin e. Administration of drugs causing neuromuscular excitation

ANS: B C D The management of tetanus includes administration of a tetanus toxoid, diphtheria toxoid, and pertussis (Tdap) booster and tetanus immune globulin in different sites to neutralize circulating toxins. Opioid analgesics such as morphine or fentanyl are indicated for pain management. Control of spasms is essential and is managed by sedation and skeletal muscle relaxation, usually with diazepam and barbiturates. Drugs causing neuromuscular excitation would worsen the condition, but neuromuscular blocking agents such as vecuronium that act to paralyze skeletal muscles can be given if the condition deteriorates further. This condition is caused by the bacteria Clostridium tetani, which would not be eliminated by administering antiviral drugs.

A patient who came to the hospital two days ago is diagnosed with Guillain Barré syndrome. Plasmapheresis is planned to treat the condition. What criteria are used to determine if this treatment is effective? Select all that apply. a. Urinary output is at least 30 mL per hour. b. Stabilization of blood pressure and pulse rate. c. Symptoms of paralysis stop progressing and abate. d. Lung vital capacity and arterial blood gases are stable. e. Blood urea nitrogen (BUN) and creatinine levels are within normal levels.

ANS: B C D Guillain Barré syndrome is a polyneuropathic condition resulting from an immune response following some type of infection. Symptoms include paresthesia with ascending bilateral paralysis as demyelination of the nerves occurs. The paralysis starts in the extremities and can advance to the thoracic area, resulting in respiratory failure. Disturbance in the autonomic nervous system causes episodes of hypotension, hypertension, and bradycardia. Treatment is successful with the halt of paralysis and stabilization of cardiovascular function and respiratory status. BUN and creatinine levels and urinary output are measures of renal function.

The nurse recognizes that which medications are considered to be first-line drugs for treatment of trigeminal neuralgia? Select all that apply. a. Baclofen b. Phenytoin c. Topiramate d. Gabapentin e. Clonazepam f. Carbamazepine

ANS: B C E F Phenytoin, topiramate, clonazepam, and carbamazepine are first-line drug therapies for trigeminal neuralgia. These are antiseizure drugs that may reduce pain by stabilizing the neuronal membrane and blocking nerve firing. Baclofen or gabapentin may be used in combination with any of the antiseizure drugs if a single drug is not effective.

The patient with trigeminal neuralgia asks the nurse about the incidence and how this condition is diagnosed. Which responses by the nurse are most accurate? Select all that apply. a. "It occurs twice as often in men than women." b. "90% of the cases occur in people over age 50." c. "It is one of the most commonly diagnosed neuralgic conditions." d. "Risk factors include rheumatoid arthritis and primary epilepsy." e. "The cause and physical aspects of trigeminal neuralgia are not well known." f. "Every year, about 12 in 100,000 Americans are diagnosed with this condition."

ANS: B C E F Trigeminal neuralgia is a common neuralgic condition with poorly known etiology and pathology that generally occurs in people over age 50. Each year about 12 in 100,000 Americans are diagnosed with this condition. The disease occurs more often in women than men. Risk factors include patients with herpesvirus infections, infection of the teeth and jaw, and brain stem infarct.

A patient has had two episodes of trigeminal neuralgia and has lately been exhibiting strange mannerisms. The nurse identifies them to be coping strategies to avoid another episode. What observed mannerisms would have led the nurse to conclude this? Select all that apply. a. Patient avoids sleeping. b. Patient has stopped eating. c. Patient avoids blinking the eye. d. Patient covers the face with a cloth. e. Patient avoids interacting with people.

ANS: B D E A triggering mechanism can initiate painful episodes in trigeminal neuralgia. The triggers may include a light touch at a specific point along the distribution of the nerve branches. It can be precipitated by chewing, tooth brushing, feeling a hot or cold blast of air on the face, washing the face, yawning, or even talking. Therefore the patient may avoid these activities to prevent painful episodes. As a result, the patient may not chew food and may eat improperly, may cover the face with a cloth, and may withdraw from interaction with other individuals. The patient may sleep excessively as a means of coping with the pain. Movement of eyes does not trigger a painful episode.

The nurse is performing a physical assessment of a patient with Bell's palsy. What clinical manifestations is the nurse likely to find? Select all that apply. a. Narrowed palpebral fissure b. Flattening of the nasolabial fold c. Grimacing and frequent blinking d. Flaccidity of the affected side of the face e. Drooping of the mouth accompanied by drooling

ANS: B D E Bell's palsy is characterized by inflammation of the facial nerve (CN VII) on one side of the face in the absence of any other disease such as a stroke. Paralysis of the motor branches of the facial nerve typically results in flaccidity of the affected side of the face, with drooping of the mouth accompanied by drooling. Nasolabial folds may flatten due to facial nerve inflammation and its impact on the muscle. Grimacing and frequent blinking are clinical manifestations of trigeminal neuralgia and not Bell's palsy. The patient may also have a widened palpebral fissure, not narrowed palpebral fissures.

A patient has been diagnosed with botulism. The nurse is explaining to the patient and the caregivers about the pathology involved in the disease. What points should the nurse emphasize while explaining it? Select all that apply. a. Botulism is a water-borne disease. b. The spores of the organism are difficult to destroy. c. This neurotoxin damages the gray matter of the brain. d. This neurotoxin inhibits nerve impulses from reaching the muscle. e. The neurotoxin produced by the bacteria is absorbed in the gastrointestinal (GI) tract.

ANS: B D E Botulism is caused by GI absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin destroys or inhibits the neurotransmission of acetylcholine at the myoneural junction, resulting in disturbed muscle innervation. This organism is found in the soil, and the spores are difficult to destroy. Botulism is rare but is the most serious type of food poisoning; it is not a water-borne disease. The neurotoxin affects the myoneural junction and not the nerve cell bodies, and so the grey matter of the brain is not damaged in this condition.

The nurse is caring for a patient with Guillain-Barré syndrome. What signs and symptoms should the nurse continuously monitor for in this patient? Select all that apply. a. Continuous tonic seizures b. Presence of bed sores c. Stiffness in the jaw and neck d. Changes in bladder function e. Respiratory rate and rhythm

ANS: B D E Immobility from the paralysis can cause problems such as bed sores. Bladder function may be disrupted due to urinary tract infection. The most serious complication is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Constant monitoring of the respiratory system by checking respiratory rate and depth provides information about the need for immediate intervention, including intubation and mechanical ventilation. Continuous tonic seizures and stiffness in the jaw do not occur in Guillain-Barré syndrome. These are manifestations of tetanus.

A patient's surgical therapy for trigeminal neuralgia resulted in an altered corneal reflex. The nurse provides education about long-term management of the reflex. Which statements made by the patient indicate the need for further teaching? Select all that apply. a. "I will examine my eyes regularly." b. "I will go for an annual dental visit." c. "I will check my oral cavity after meals." d. "I will chew food on the unaffected side." e. "I will avoid ice cream and cold beverages."

ANS: B E If the patient says that an annual dental visit is needed, then there is need for further teaching. The nurse should teach the patient to have semi-annual dental visits. There is no need to avoid ice creams and cold beverages. However, hot food and beverages should be avoided, because these can burn the mucous membrane. The patient needs to examine his or her eyes regularly for symptoms of infection or irritation. The oral cavity should be checked after meals to remove residual food particles. The patient should chew food on the unaffected side of the mouth.

The nurse would assess for trigeminal neuralgia in patients with which conditions? Select all that apply. a. Hypotension b. Multiple sclerosis c. Viral immunization d. Food contamination e. Herpesvirus infection

ANS: B E Multiple sclerosis and herpesvirus infection are conditions associated with trigeminal neuralgia. Hypertension, rather than hypotension, is associated with trigeminal neuralgia. Viral immunizations may put patients at risk for Guillain-Barre syndrome (GBS). Food contaminated with Clostridium botulinum may increase risk for botulism.

A patient asks the nurse about the differences between trigeminal neuralgia and Bell's palsy. What symptoms of trigeminal neuralgia should the nurse include in the teaching? Select all that apply. a. Hearing deficits b. Tearing of the eye c. Pain behind the ear d. Drooping of the mouth e. Pain on the side of the nose

ANS: B E Trigeminal neuralgia may cause tearing of the eye during an acute attack. This is not seen in patients with Bell's palsy. Trigeminal neuralgia may also cause excruciating pain described as a burning, knifelike, or lightning-like shock on parts of the face including the side of the nose. In patients with Bell's palsy, pain may be present behind the ear on the affected side, especially before the onset of paralysis. Drooping of the mouth is a feature of Bell's palsy, not trigeminal neuralgia. Although alterations in sensory functions may occur with both trigeminal neuralgia and Bell's palsy, there are differences. Patients with trigeminal neuralgia may experience facial sensory loss, whereas patients with Bell's palsy may have hearing deficits or unilateral loss of taste sensations.

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority ? a. Pain assessment b. Glasgow coma scale c. Respiratory assessment d. Musculoskeletal assessment

ANS: C Although all of the assessments are necessary in the care of patients with Guillain-Barré syndrome, the acute risk of respiratory failure necessitates vigilant monitoring of the patient's respiratory status.

Which cranial nerve does the nurse know is associated with tic douloureux? a. I b. III c. V d. VII

ANS: C Cranial nerve V is the trigeminal nerve, which is involved with trigeminal neuralgia, also known as tic douloureux. Most cases result from vascular compression of the trigeminal nerve root by an abnormal loop of the superior cerebral artery. Cranial nerve I is the olfactory nerve, which is responsible for the sense of smell. Cranial nerve III is the oculomotor nerve, which is responsible for raising eyelids, moving eyes, regulating the size of pupils, and focusing lenses. Cranial nerve VII is the facial nerve, which is responsible for facial expression and taste.

A patient is diagnosed with Bell palsy. Which cranial nerve does the nurse teach the patient is associated with the disorder? a. II b. V c. VII d. XII

ANS: C Cranial nerve VII is the facial nerve; when it becomes inflamed, it is responsible for Bell palsy, a paralysis or weakness of the muscles on one side of the face. Cranial nerve II is the optic nerve associated with vision. Cranial nerve V is the trigeminal nerve, which is associated with sensation of the face and motor functions such as biting and chewing. Cranial nerve XII is the hypoglossal nerve, which is responsible for tongue movement.

The nurse differentiates between the clinical manifestations of Guillain-Barre syndrome (GBS) that are related to autonomic nervous system dysfunction and those that are related to cranial nerve involvement. What does the nurse identify as a clinical manifestation that is related to the autonomic nervous system? a. Dysphagia b. Tachycardia c. Facial flushing d. Facial weakness

ANS: C Facial flushing is a manifestation of Guillain-Barre syndrome (GBS) that results from autonomic nervous system dysfunction. Dysphagia occurs due to cranial nerve involvement. Autonomic nervous system dysfunction causes bradycardia, rather than tachycardia in patients with Guillain-Barre syndrome (GBS). Facial weakness is a result of cranial nerve involvement.

What body system is the major focus for nursing care of the patient with Guillain-Barré syndrome? a. Urinary b. Cardiac c. Respiratory d. Gastrointestinal

ANS: C Guillain-Barré syndrome is an autoimmune disease that destroys the myelin sheath covering peripheral nerves. Symptoms range from mild to severe, potentially as far as full-body paralysis. Frequently the muscles controlling respiratory function are affected, resulting in respiratory failure. The disease causes rapid, progressive, symmetrical loss of motor function that ascends from the extremities to the head. Although Guillain-Barré syndrome may affect some functions of the urinary, cardiac, and gastrointestinal systems, respiratory status is most important for the nurse to monitor.

The nurse caring for a patient with Bell's palsy expects to find which distinctive symptom on assessment? a. Facial pain b. Slurred speech c. An eye that will not blink d. Sagging of facial muscles

ANS: C The nonblinking eye is a cardinal sign of Bell's palsy. Facial pain, slurred speech, and sagging facial muscles are not exclusively symptoms of Bell's palsy. Facial pain may be observed in trigeminal neuralgia. Slurred speech and sagging facial muscles are commonly seen with cerebrovascular accident.

The patient with peripheral facial paresis on the left side of the face is diagnosed with Bell's palsy. What should the nurse include in teaching the patient about self-care? Select all that apply. a. Administration of antiseizure medications b. Preparing for a nerve block to relieve pain c. Administration of corticosteroid medications d. Dark glasses and artificial tears to protect the eyes e. Surgeries available if conservative therapy is not effective

ANS: C D Self-care for Bell's palsy includes corticosteroid medications to decrease inflammation of the facial nerve (CN VII) and protecting the cornea from drying out because of the inability to close the eyelid. Antiseizure medications, a nerve block, or surgeries are used for trigeminal neuralgia, not Bell's palsy

A patient has had three episodes of trigeminal neuralgia and has stopped eating food, fearing that chewing would trigger pain. What advice should the nurse give that would help to maintain a proper nutritional status of this patient? Select all that apply. a. Advise the patient to eat food that is hot. b. Encourage the patient to limit fluid intake. c. Advise the patient to consume food that is easy to chew. d. Advise the patient to eat small quantities of food more frequently. e. Advise the patient to eat food that is rich in carbohydrates and proteins.

ANS: C D E Chewing food could predispose the patient to an episode of trigeminal neuralgia; therefore in anticipation of an episode, the patient may stop eating. In such a case, the nurse should advise the patient to consume food that is easy to chew. Food should be high in protein and calories to meet nutritional demand. Small meals should be taken more frequently. Encourage the patient to take adequate amounts of fluids, because they do not require chewing. Food should be served lukewarm so that it becomes easier to chew.

A percutaneous radiofrequency rhizotomy procedure has been planned for a patient with trigeminal neuralgia. What information should the nurse give to this patient about the procedure? Select all that apply. a. Patient will be well-sedated during this procedure. b. A small craniotomy will be performed behind the ear. c. Patient may experience facial numbness after the surgery. d. Patient may have difficulty with eye movements after the procedure. e. Patient may have difficulty in masticating effectively for some time after the procedure.

ANS: C D E Percutaneous radiofrequency rhizotomy is an outpatient procedure consisting of placing a needle into the trigeminal rootlets that are adjacent to the pons and destroying the area by means of a radiofrequency current. This can result in facial numbness, corneal anesthesia (resulting in difficulty in eye movement), and trigeminal motor weakness. The trigeminal nerve supplies the muscles involved in mastication; therefore the surgery may affect mastication. Patients need to know that they will be awake during local procedures so that they can cooperate when corneal and ciliary reflexes and facial sensations are checked. A craniotomy is not required for this procedure, because it only involves placing a needle. A craniotomy is required in microvascular decompression of the trigeminal nerve.

A patient has been diagnosed with trigeminal neuralgia. For which etiologic factors should the nurse assess the patient? Select all that apply. a. Sarcoidosis b. Lyme disease c. Brainstem infarct d. Herpes virus infection e. Infection of the teeth and jaw

ANS: C D E The etiologic factors of trigeminal neuralgia include herpesvirus infection, infection of the teeth and jaw, and brainstem infarct. Sarcoidosis and Lyme disease do not cause trigeminal neuralgia; they are etiologic factors for Bell's palsy.

The respiratory status of a patient with Guillain-Barré syndrome is deteriorating. What nursing interventions should be performed for this patient? Select all that apply. a. Obtain prescription for steroid inhaler. b. Administer bronchodilators, as prescribed. c. Check for fever, and send for sputum culture. d. Keep necessary equipment ready for mechanical ventilation and tracheostomy. e. Regular pulmonary functions tests and arterial blood gas (ABG) should be taken.

ANS: C D E This patient is highly likely to develop respiratory infections. If fever develops, obtain sputum cultures to identify the pathogen. Appropriate antibiotic therapy is then initiated. The most serious complication is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Monitoring the vital capacity and ABGs is essential. If the vital capacity drops to less than 800 mL or the ABGs deteriorate, endotracheal intubation or tracheostomy may be done so that the patient can be mechanically ventilated. Administration of bronchodilators or steroids will not improve the condition of the patient, because the respiratory failure is being caused by the paralysis of respiratory muscles.

A patient having trigeminal neuralgia has been prescribed antiseizure drugs. The patient asks the nurse about how the drug would prevent painful episodes. What explanation should the nurse give in order to explain the mechanism of action of the drug? a. It blocks the perception of pain sensation. b. It reduces the pain by treating underlying depression. c. It anesthetizes the area supplied by the trigeminal nerve. d. It attenuates the transmission of nerve impulses from the trigeminal nerve.

ANS: D Antiseizure drug therapy may reduce pain by stabilizing the neuronal membrane and blocking nerve firing. These drugs do not block the perception of pain sensation like opioids, nor do these drugs anesthetize the area supplied by the trigeminal nerve. These drugs do not act as antidepressants.

When providing care to a patient on a neurologic unit, the nurse notes that the patient is experiencing areflexia. Which diagnosis does the nurse anticipate for this patient? a. Tetanus b. Botulism c. Neurosyphilis d. Guillain-Barré syndrome

ANS: D Areflexia is a clinical manifestation of Guillain-Barré syndrome. Areflexia occurs because of demyelination, edema, and inflammation of the nerves. The expected clinical manifestations of tetanus include trismus (stiffness of the jaw), neck stiffness, and signs of infection such as fever. Clinical manifestations associated with botulism include descending paralysis with muscle incoordination and weakness, difficulty swallowing, seizures, and respiratory muscle weakness. Neurosyphilis, which is caused by Treponema pallidum, manifests as vague, sharp pain in the leg, ataxia, a slapping gait, a loss of proprioception and deep tendon reflexes, and zones of hyperesthesia.

A patient develops Bell's palsy weeks after being diagnosed with a middle ear infection. What explanation should the nurse give when asked about the cause of the condition? a. A blood clot causes a small stroke, affecting the facial muscles. b. The eustachian tube becomes blocked, leading to a bulging eardrum. c. The flow of cerebrospinal fluid (CSF) in the brain is blocked temporarily. d. A virus causes inflammation, which leads to paralysis of the facial nerve.

ANS: D Bell's palsy, or peripheral facial paralysis, causes mouth droop and the inability to close the eyelid, usually on one side. A viral infection is thought to cause inflammation and eventually demyelination of the nerve. Most patients recover fully with treatment within three to six months. Facial weakness, which occurs with a stroke, is caused by a blood clot stopping blood flow to the area of the brain. An inflamed eustachian tube can block drainage from the middle ear, leading to otitis media, a middle ear infection. The flow of CSF is normally blocked temporarily whenever there is an increase in intraabdominal pressure, as with coughing.

The nurse is providing care to a patient with trigeminal neuralgia. Which first-line drug prescribed to this patient does the nurse prepare to administer? a. Baclofen b. Gabapentin c. Amitriptyline d. Carbamazepine

ANS: D Carbamazepine is a first-line drug used in the treatment of trigeminal neuralgia. It is an anticonvulsant. Baclofen is a γ-aminobutyric acid receptor agonist used in combination with antiseizure drugs if a single agent is not effective. Amitriptyline is a tricyclic antidepressant that is used to treat constant burning or aching pain, which are manifestations of trigeminal neuralgia. Gabapentin is used as an anticonvulsant and analgesic. It is also used in combination with antiseizure drugs if a single drug is not effective.

The nurse provides preoperative information to a patient with trigeminal neuralgia. The nurse explains that the surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current. What surgery is planned for the patient? a. Glycerol rhizotomy b. Gamma knife radiosurgery c. Microvascular decompression d. Percutaneous radiofrequency rhizotomy

ANS: D Percutaneous radiofrequency rhizotomy is an intracranial procedure that involves the destruction of sensory fibers by low-voltage current. Glycerol rhizotomy is a peripheral procedure in which glycerol is injected into one or more branches of the trigeminal nerve to cause chemical ablation. Gamma knife radiosurgery is an intracranial technique that uses high doses of radiation focused on the trigeminal nerve root using stereotactic localization. Microvascular decompression is an intracranial procedure in which the artery pressing on the nerve root is lifted up and repositioned.

A patient with Guillain-Barré syndrome is admitted to the medical-surgical floor. What does the nurse understand regarding this disorder? a. Pain is generally worse during the day. b. It affects males twice as often as females. c. Heart failure (HF) is the most serious complication of this condition. d. Patients also may have syndrome of inappropriate antidiuretic hormone (SIADH).

ANS: D Syndrome of SIADH also can occur in patients with Guillain-Barré syndrome. The pain, which is manifested by paresthesias, generally is worse at night and the most serious complication is respiratory failure. Guillain-Barré syndrome affects males 1.5 times more frequently than females.

A patient diagnosed with Guillain-Barré syndrome has a weak gag reflex. For which complication associated with a weak gag reflex should the nurse intervene? a. Severe vomiting b. Difficulty breathing c. Impaired taste sensations d. Aspiration of food into the airways

ANS: D The gag reflex is a protective mechanism of the body to prevent anything from entering the respiratory tract via the throat. Therefore, a weak gag reflex may cause aspiration, and the nurse should be watchful for this condition. In addition to testing for the gag reflex, the nurse should note drooling and other difficulties with secretions that may indicate an inadequate gag reflex. Manually eliciting a strong gag reflex may cause vomiting. The nurse should intervene if the patient has severe vomiting, difficulty breathing, or impaired taste sensation; however, these symptoms are not caused by a weak gag reflex.

Which of the following assessment findings demonstrates effective use of carbamazepine in the patient with trigeminal neuralgia? a. Less difficulty swallowing. b. Ability to close both eyes. c. Presence of the corneal reflex. d. Less frequent and severe facial pain.

ANS: D Trigeminal neuralgia is very severe episodic pain that occurs in the area innervated by the trigeminal nerve, the face, and jaw. Improvement consists of a decrease in the frequency and severity of pain. The corneal or blink reflex is a normal finding and usually is not affected by trigeminal neuralgia. The ability to close both eyes involves the motor function of the facial (seventh) cranial nerve.

A patient with trigeminal neuralgia is scheduled for microvascular decompression of the trigeminal nerve. What is appropriate for the nurse to teach the patient about the procedure? Select all that apply. a. "It may cause loss of sensation in the cornea." b. "It may cause some amount of numbness in your face." c. "It will involve injection of glycerol into the trigeminal nerve." d. "It will be performed by making a small hole behind your ear." e. "It is one of the safest surgical treatments for trigeminal neuralgia." f. "It involves displacement of the blood vessels pressing on the nerve."

ANS: D F The nurse should explain to the patient that a small hole will be made in the skull behind the ear. This is called suboccipital craniotomy. Microvascular decompression involves displacement and repositioning of the blood vessels pressing on the patient's trigeminal nerve. It relieves pain without any sensory loss. Therefore there should be no loss of corneal sensation or numbness in the face. Microvascular decompression does not involve injection of glycerol. Glycerol rhizotomy involves injection of glycerol into the trigeminal cistern. Although there is no residual sensory loss with microvascular decompression, it is potentially dangerous because it involves an intracranial procedure.