chapter 69- Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? Assess the respiratory rate and oxygen saturation. Assess the blood pressure and heart rate. Assess the peripheral pulses. Listen to the bowel sounds.

Assess the blood pressure and heart rate.

The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply. Have the patient take a hot tub bath to allow muscle relaxation. Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Assist with a rigorous exercise program to prevent contractures.

Demonstrate daily muscle stretching exercises, Apply warm compresses to the affected areas, Allow the patient adequate time to perform exercises

A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease? Glucose in the CSF Elevated protein levels in the CSF Red blood cells present in the CSF White blood cells in the CSF

Elevated protein levels in the CSF

When caring for a client with trigeminal neuralgia, which intervention has the highest priority? Providing emotional support while the client adjusts to changes in his physical appearance Monitoring intake and output Assisting with ambulation Encouraging the client to bathe with care

Encouraging the client to bathe with care

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients? Gag reflex and bowel sounds Condition of skin Respiratory status Urinary output and capillary refill

Gag reflex and bowel sounds

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? Use pressure-relieving devices when the client is in bed or in a wheelchair. Change body position every 2 hours. Help the client perform range-of-motion (ROM) exercises every 8 hours. Use a footboard and trochanter rolls.

Help the client perform range-of-motion (ROM) exercises every 8 hours.

A health care provider asks a nurse to assess a patient being evaluated for aseptic meningitis for a positive Brudzinski sign. Which of the following actions should the nurse take? Assess the patient's sensitivity to light. Support the patient's neck through normal range of motion and evaluate stiffness. Help the patient flex his neck and observe for flexion of the hips and knees. Flex the patient's thigh on his abdomen and assess the extension of the leg.

Help the patient flex his neck and observe for flexion of the hips and knees.

The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? Maintains effective respirations and airway clearance Shows increasing mobility Receives adequate nutrition and hydration Demonstrates recovery of speech

Maintains effective respirations and airway clearance

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? Sleep pattern Mood and affect Appetite Muscle spasms

Muscle spasms

During the acute phase of a debilitating cerebrovascular accident, which nursing intervention is most helpful in promoting the rehabilitation of the client? Prevention of joint contractures Promotion of critical thinking ability Creation of a positive environment Use of adaptive equipment

Prevention of joint contractures

Which of the following is the first-line therapy for myasthenia gravis (MG)? Pyridostigmine bromide (Mestinon) Deltasone (Prednisone) Azathioprine (Imuran) Lioresal (Baclofen)

Pyridostigmine bromide (Mestinon)

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Sphygmomanometer Padded tongue blade Nasal cannula and oxygen Suction machine with catheters

Suction machine with catheters

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? The client grasps the affected arm at the wrist and raises it. The client arranges a community service to deliver meals. The client ambulates with the assistance of one. The client uses a mechanical lift to climb steps.

The client grasps the affected arm at the wrist and raises it.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? The client will take the seizure medication at the same time daily. The client will remain free of injury if a seizure does occur. The client will verbalize an understanding of feelings that preempt seizure activity. The client will post emergency numbers on the refrigerator for ease of obtaining.

The client will remain free of injury if a seizure does occur.

A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? The muscles will become fatigued and the patient will not be able to chew food or swallow pills. There should not be a problem, since the medication was only delayed by about 2 hours. The patient will go into cardiac arrest. The patient will require a double dose prior to lunch.

The muscles will become fatigued and the patient will not be able to chew food or swallow pills.

A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? Warm, dry skin Urine output of 40 ml/hour Soft, nondistended abdomen Uneven, labored respirations

Uneven, labored respirations

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: take a hot bath. rest in an air-conditioned room. increase the dose of muscle relaxants. avoid naps during the day.

rest in an air-conditioned room.