Chapter 69

A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process?

Acyclovir (Zovirax)

A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient?

EEG

A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patients care, the nurse addresses the need to enhance the patients bladder control. What aspect of nursing care is most likely to meet this goal?

Establish a timed voiding schedule.

A middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?

Difficulty in coordination

A patient is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the patients complaints of headache?

Dimming the lights and reducing stimulation

You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?

Increased muscle strength

The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly patients with MS are known to be particularly concerned about what variables? Select all that apply.

Possible nursing home placement Increasing disability Becoming a burden on the family

A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?

The patient needs to be assessed for MS.

The nurse is developing a plan of care for a patient with Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this patient?

Using the incentive spirometer as prescribed

The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurses communication with the patient should reflect the possibility of what sign or symptom of the disease?

Vocal paralysis

A patient diagnosed with Bells palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?

Applying a protective eye shield at night

To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment?

Blood levels of the drug must be monitored.

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?

Blurred vision, intention tremor, and urinary hesitancy

A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?

Close monitoring of fluid balance

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis?

Neck flexion produces flexion of knees and hips

The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?

Autonomic dysfunction

The nurse is developing a plan of care for a patient newly diagnosed with Bells palsy. The nurses plan of care should address what characteristic manifestation of this disease?

Facial paralysis

The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurses best response?

Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.

A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?

Many symptoms can be the result of normal aging process.

The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?

Resting in an air-conditioned room whenever possible

A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?

The patient should be monitored for bone marrow depression.

A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what?

Determined by the patients response

The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?

Avoid rubbing the eye on the affected side of the face.

A 35-year-old woman is diagnosed with a peripheral neuropathy. When making her plan of care, the nurse knows to include what in patient teaching? Select all that apply.

Inspect the lower extremities for skin breakdown. Footwear needs to be accurately sized. Assistive devices may be needed to reduce the risk of falls.

The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patients care plan?

Instruct the patient on daily muscle stretching.

The nurse is planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?

Washing his face

A patient diagnosed with Bells palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?

Whistling

The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?

A lower motor neuron lesion

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patients safety, what nursing action should be performed?

Ensure that suction apparatus is set up at the bedside.

A patient diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen (Lioresal). What should the nurse identify as an expected outcome of this treatment?

Decreased muscle spasms in the lower extremities

A 69-year-old patient is brought to the ED by ambulance because a family member found him lying on the floor disoriented and lethargic. The physician suspects bacterial meningitis and admits the patient to the ICU. The nurse knows that risk factors for an unfavorable outcome include what? Select all that apply.

Heart rate greater than 120 bpm Older age Low Glasgow Coma Scale

A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?

In the morning, with frequent rest periods

The nurse is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?

MS is a progressive demyelinating disease of the nervous system.

The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?

Monitoring neurologic status closely

A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patients nursing care should involve which of the following?

Passive and active ROM exercises for the affected limb

A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?

Peripheral nerve disorder

A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?

Position the patient upright during feeding.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection?

Positive Kernigs sign

A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action?

Prepare to assist with intubation.

The critical care nurse is admitting a patient in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient?

Providing ventilatory assistance