Ch 44 Care of patients with Problems of the Peripheral Nervous System

b. Sudden onset of weakness in the legs e. Double vision f. Uncoordinated movements

1. The nurse is assessing a patient with a diagnosis of Guillain-Barré syndrome. Which signs and symptoms would the nurse expect to observe? Select all that apply. a. Bilateral sluggish pupil response b. Sudden onset of weakness in the legs c. Muscle atrophy of the legs d. Change in level of consciousness e. Double vision f. Uncoordinated movements

c. Anaphylaxis

10. A patient with Guillain-Barré syndrome is receiving IV immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. Ventricular fibrillation b. Hypertensive crisis c. Anaphylaxis d. Malignant hyperthermia

b. "He'll never be able to walk again."

12. A patient has been newly diagnosed with Guillain-Barré syndrome. The nurse is teaching the patient and family about the condition. Which statement by the family indicates a need for additional teaching? a. "He could recover in 4 to 6 months." b. "He'll never be able to walk again." C. "He will receive medication for pain." d. "He will be monitored for breathing problems."

a. Maintain airway patency and gas exchange.

14. What is the priority expected outcome in a patient with Guillain-Barré syndrome? a. Maintain airway patency and gas exchange. b. Promote communication. c. Manage pain and discomfort. d. Prevent complications of immobility.

b. Recent bacterial infection

15. The nurse is reviewing the admission and history notes for a patient admitted for Guillain-Barré syndrome (GBS). Which medical condition is most likely to be present before the onset of GBS? a. Diabetes mellitus b. Recent bacterial infection c. Peripheral vascular disease d. Addison disease

a. Motor weakness that starts in legs and then spreads to arms and upper body

16. The patient has Guillain-Barré syndrome with ascending paralysis. What would the nurse expect to observe? a. Motor weakness that starts in legs and then spreads to arms and upper body b. Extensive paralysis similar to quadriplegia, but sensory function is retained C. Motor weakness and fatigue that progres- throughout the day sively worsens d. Paralysis that is worse in the upper body, particularly the arms and hands

a. Perform passive range of motion every 2-4 hours

17. To maintain mobility for the patient with Guillain-Barré syndrome, which intervention is best for the nurse to delegate to unlicensed assistive personnel? a. Perform passive range of motion every 2 to 4 hours. b. Turn the patient every 2 hours and assess for skin breakdown. C. Ask the patient if he feels strong enough to go to physical therapy. d. Assist the patient to ambulate in the hall several times during the shift.

C. Elective intubation

2. During shift report, the nurse hears that a patient with Guillain-Barré syndrome has a decrease in vital capacity that is less than two- thirds of normal, and there is a progressive inability to clear and cough up secretions. The health care provider has been notified and is coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient? a. Frequent oral suctioning b. Rigorous chest physiotherapy C. Elective intubation d. Elective tracheostomy

a. Respiratory effort improves

21. The nurse is caring for a patient who is slowly recovering from Guillain-Barré syndrome with ascending paralysis. Which sign of physical recovery would the nurse expect to see first? a. Respiratory effort improves b. Gross motor of arms improves C. Fine motor of fingers returns d. Movement of lower legs returns

C. Cranial nerve VII

22. The nurse asks a patient with Guillain-Barré syndrome to smile, frown, whistle, and drink from a straw. Which cranial nerve is the nurse assessing? a. Cranial nerve I b. Cranial nerve II C. Cranial nerve VII d. Cranial nerve X

d. Stick the tongue straight out.

23. To assess the hypoglossal nerve (cranial nerve XII), what will the nurse ask the patient to do? a. Blink eyelids and raise eyebrows. b. Read an eye chart or newspaper. C. Demonstrate a deep cough. d. Stick the tongue straight out.

a. Ptosis b. Diplopia d. Ocular palsies f. Fatigue

24. The nurse is assessing a patient with myasthenia gravis. Which manifestations can the nurse expect to observe? Select all that apply. a. Ptosis b. Diplopia c. Delayed pupillary responses to light d. Ocular palsies e. Decreased pupillary accommodation f. Fatigue

a. Patient has more trouble with mobility when he is fatigued.

28. The nurse is caring for a patient with myasthenia gravis. What problem does the nurse expect the patient to have? a. Patient has more trouble with mobility when he is fatigued. b. Patient has difficulty sleeping, and wakes around 3:00 AM. c. Patient is disorientated in the late afternoon. d. Patient has pain that interferes with activities of daily living.

C. Review weekly serum prealbumin level

3. A patient with Guillain-Barré syndrome is identified as having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this patient's nutritional status? A. Check skin turgor and urinary output B. Give enteral feedings via feeding tube C. Review weekly serum prealbumin level D. Review potassium and sodium levels

C. Ability to chew and swallow

30. What is the priority nursing assessment for a patient with myasthenia gravis? a. Presence of pain in the extremities b. Loss of bowel and bladder function C. Ability to chew and swallow d. Quality and volume of the voice

b. Voice may become weaker or exhibit a nasal twang.

31. A patient with myasthenia gravis and the nurse are having a long discussion about plans for the future. After an extended conversation, what does the nurse anticipate will occur in this patient? A. Speech will be slurred and difficult to understand B. Voice may become weaker or exhibit a nasal twang C. Voice quality will become harsh and strident D. Voice will become toneless and affect will be flat

C. Medication times

33. The nurse is planning activities for a patient with myasthenia gravis. Which factor does the nurse consider to promote self-care, yet prevent excessive fatigue? a. Time of day b. Severity of symptoms C. Medication times d. Sleep schedule

c. Inability to swallow

35. The nurse is caring for a patient recently diagnosed and admitted with myasthenia gravis. During the morning assessment, the nurse notes some abnormal findings. Which symptom is cause for the greatest concern? a. Diarrhea b. Fatigue c. Inability to swallow d. Difficulty opening eyelids

d. Bradycardia

4. A patient with Guillain-Barré syndrome has been intubated for respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the patient for? a. Tachypnea b. Atrial fibrillation c. Cyanosis d. Bradycardia

a. Schedule activities after medication administration.

42. A patient with myasthenia gravis has generalized weakness and fatigue and is limited in the ability to perform activities of daily living (ADLS). Which nursing action is best to help this patient avoid excessive fatigue? a. Schedule activities after medication administration. b. Schedule activities during the late after- noon or early evening. c. Encourage ambulation during periods of maximal strength. d. Instruct unlicensed assistive personnel to assist with all ADLS.

b. "How to Prepare for Your Surgical Thymectomy"

46. A patient with myasthenia gravis has been referred to a surgeon for a procedure that may improve the patient's symptoms. Which brochure would the nurse prepare for the patient? a. "What Is Percutaneous Stereotactic Rhizotomy?" b. "How to Prepare for Your Surgical Thymectomy" c. "Expected Outcomes for Microvascular Decompression" d. "Stereotactic Radiation Treatments by Gamma Knife"

b. "We should do hygienic care for her to avoid undue frustration and fatigue."

48. The nurse is performing teaching for the family of a patient with myasthenia gravis about fatigue and activities of daily living. Which statement by a family member indicates a need for additional teaching? a. "Rest is critical because increased fatigue can precipitate a crisis." b. "We should do hygienic care for her to avoid undue frustration and fatigue." c. "Activities should be done after we give her the medication." d. "The physical therapist will be able to recommend some energy-saving devices."

a. Instruct patient to speak slowly. c. Ask yes or no questions. d. Use system of eye blinking. e. Have patient use a picture, letter, or word board.

49. A patient with myasthenia gravis is experiencing impaired communication related to weakness of the facial muscles. Which interventions are best in assisting the patient to communicate with the staff and family? Select all that apply. a. Instruct patient to speak slowly. b. Use short, simple sentences. c. Ask yes or no questions. d. Use system of eye blinking. e. Have patient use a picture, letter, or word board. f. Face patient and speak clearly.

c. Electrophysiologic study

5. A patient is admitted for a probable diagnosis of Guillain-Barré syndrome but needs additional diagnostic testing for confirmation. Which test does the nurse anticipate will be ordered for this patient? a. Electroencephalography b. Cerebral blood flow c. Electrophysiologic study d. Electrocardiogram

a. Perform daily weights.

50. A patient with myasthenia gravis is having difficulty maintaining an adequate intake of food and fluid because of difficulty chewing and swallowing. Which task for this patient is best to delegate to unlicensed assistive personnel? a. Perform daily weights. b. Monitor calorie counts. c. Ask about food preferences. d. Evaluate intake and output.

a. Increase in CSF protein level

6. The nurse is reviewing the cerebral spinal fluid (CSF) results for a patient with probable Guillain-Barré syndrome, who has been having symptoms for several weeks. Which abnormal finding is most likely to be seen at this time? a. Increase in CSF protein level b. Increase in CSF glucose level C. Cloudy appearance of CSF d. Elevation of lymphocyte count in CSF

b. Myasthenia gravis

65. The patient tells the nurse that he is waiting for results of repetitive nerve stimulation testing. While waiting for the test results, the nurse is vigilant for signs and symptoms of which disorder? a. Guillain-Barré syndrome b. Myasthenia gravis C. Restless leg syndrome d. Trigeminal neuralgia

C. IV immunoglobulin is slowly infused when it is started.

7. An ambulatory patient has sought treatment for symptoms of Guillain-Barré syndrome. IV immunoglobulin therapy has been prescribed. Which precaution does the nurse expect with this therapy? A. IV immunoglobulin is given concurrently with plasmapheresis. B. A shunt must be placed prior to beginning the therapy. C. IV immunoglobulin is slowly infused when it is started. d. Three or four treatments are given 1 to 2 days apart.

a. Elevate the head of the bed at least 45 degrees. b. Assess for dysphagia prior to giving oral fluids or medications. d. Have suctioning equipment available at the bedside.

8. The patient with Guillain-Barré syndrome is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? Select all that apply. a. Elevate the head of the bed at least 45 degrees. b. Assess for dysphagia prior to giving oral fluids or medications. c. Teach coughing and deep-breathing exercises. d. Have suctioning equipment available at the bedside. e. Turn the patient from side to side at least every 2 hours. f. Restrict food and fluids until exacerbation resolves.

d. Immunity

9. What is the nursing concept that underlies the etiology and the pathophysiology of Guillain- Barré syndrome? a. Sensory perception b. Mobility C. Gas exchange d. Immunity