nur 116 - Davis Advantage / Edge - Guillain-Barré Syndrome

The nurse is performing an assessment on a patient with Guillain-Barré syndrome. What priority assessments should the nurse perform? Select all that apply. Respiratory assessment with vital capacity measurement Tactile fremitus Pain assessment Diaphragmatic excursion Motor sensory assessment

Respiratory assessment with vital capacity measurement Pain assessment Motor sensory assessment

The nurse is teaching about myasthenia gravis (MG) with a newly diagnosed patient. Which statement by the patient indicates a need for further teaching? "The symptoms include localized skeletal muscle weakness, ptosis, diplopia, and fatigue." "Penicillamine is used in the treatment of MG." "Serological tests and electromyography are used in the diagnosis of MG." "Plasmapheresis is an additional therapy used in the treatment of MG."

"Penicillamine is used in the treatment of MG." Rationale: Penicillamine is used in the treatment of rheumatoid arthritis. It can worsen or induce MG. Test Taking Tips: The presence of penicillamine will worsen myasthenia gravis (MG).

Which is true regarding percutaneous rhizotomy to treat trigeminal neuralgia? Select all that apply. -In this process, a needle is inserted through the cheek into the foramen ovale. -In this process, a lesion forms, which interrupts pain transmission to the brain. -In this process, nerve fibers are damaged or destroyed. -In this process, a shredded fluorocarbon resin pad is placed between the vessels and the nerve. -In this process, patients may experience permanent facial numbness.

-In this process, a needle is inserted through the cheek into the foramen ovale. -In this process, nerve fibers are damaged or destroyed. -In this process, patients may experience permanent facial numbness. Rationale: In percutaneous rhizotomy, a needle is inserted through the cheek into the foramen ovale. In this process, a lesion forms, which interrupts pain transmission to the brain. Rationale: Percutaneous rhizotomy, radiofrequency, glycerol injection, and balloon compression may result in damaged or destroyed nerve fibers. Rationale: In a percutaneous rhizotomy, permanent facial numbness in the region supplied by the branch may occur. Test Taking Tips: Consider the reasons for medical interventions.

Which precautionary measure should a nurse take when administering pyridostigmine to a patient when treating myasthenia gravis (MG)? Monitoring the blood glucose level, which may fluctuate Administering the medication 30 to 60 minutes before a meal Checking if calcium and vitamin D supplements have been ordered Educating the patient about side effects of steroids

Administering the medication 30 to 60 minutes before a meal Rationale: Pyridostigmine should be administered 30 to 60 minutes before meal. Test Taking Tips: Understand safe medication administration.

A patient who has undergone a Tensilon test for the detection of myasthenia gravis (MG) has developed bradycardia. Which drug will be most beneficial for the patient? Atropine Neostigmine Pyridostigmine Mycophenolate mofetil

Atropine Rationale: A Tensilon test for the detection of MG is performed by administering edrophonium IV. Atropine is a muscarinic blocker that reverses the action of edrophonium. Test Taking Tips: The nurse must know how to treat side effects of medications.

Which etiologic agents might lead to the development of Guillain-Barré syndrome? Select all that apply. Campylobacter jejuni Epstein-Barr virus Pediculosis Mycoplasma pneumoniae H. pylori

Campylobacter jejuni Epstein-Barr virus Mycoplasma pneumoniae

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Antidiuretic Hormone SIADH or DI

SIADH CORRECT. A patient who has GB with an affected cranial nerve X (CN X) may be at risk for SIADH or increased secretion of antidiuretic hormone because CN X is related to autonomic function.

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Deep Tendon Reflexes AREFLEXIA or CLONUS

AREFLEXIA CORRECT. Absence of reflexes (areflexia) is seen in patients who have GB.

Which client presentation is indicative of a clinical diagnosis of Guillain-Barré syndrome? Bilateral pitting edema of the lower extremities Areflexia Nasal congestion Petechiae

Areflexia

A patient reports a sharp, throbbing, and shocklike pain after brushing the teeth, smiling, or talking. Which medication is the most appropriate as first-line therapy? Baclofen Gabapentin Carbamazepine Oxcarbazepine

Carbamazepine Rationale: Sharp, throbbing, and shocklike pain after brushing the teeth, smiling, or talking is a symptom of trigeminal neuralgia. The first-line medication treatment is carbamazepine. Test Taking Tips: Understand medications.

Which laboratory finding of cerebrospinal fluid (CSF) indicates the presence of Guillain-Barré syndrome? Pressure: 15 mm Hg Protein: 53 mg/dL Color: cloudy, turbulent Specific gravity: 1.007

Protein: 53 mg/dL Rationale: The normal level of protein in CSF is 15 to 50 mg/dL. A level greater than 50 mg/dL may indicate the presence of Guillain- Barré syndrome. Test Taking Tips: Consider cerebrospinal fluid (CSF) findings.

In what stage of Guillain-Barré syndrome does remyelination and axonal regeneration begin? Sub-acute stage Acute stage Plateau stage Recovery stage

Recovery stage

Which type of therapy might be needed to take care of a client diagnosed with Guillain-Barré syndrome with respiratory compromise? Dialysis Reverse isolation Mechanical ventilation Hyperbaric therapy

Mechanical ventilation

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Electromyography DECREASED NERVE CONDUCTION or EXAGGERATED NERVE CONDUCTION

DECREASED NERVE CONDUCTION CORRECT. Electromyography results in GB reveal slowed nerve conduction velocity resulting from demyelination of the nerve cells during the disease process. GB is an autoimmune disease in which destruction of peripheral nerve endings leads to alterations in function. In other words, the patient's own nerves are attacked.

What finding would the nurse expect to see in a client diagnosed with Guillain-Barré syndrome? Clonus Diarrhea Decreased nerve conduction on electromyography test results No reported abnormalities on lumbar puncture test results

Decreased nerve conduction on electromyography test results

Which clinical manifestation should a nurse look for in a patient with myasthenia gravis (MG)? Facial pain Areflexia Diplopia Paralysis

Diplopia Rationale: Symptoms such as diplopia may be seen in patients with MG. Diplopia is caused by extraocular muscle weakness, which leads to double vision. Test Taking Tips: Know medication terminology to answer questions.

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. CSF - Cerebrospinal Fluid with Normal Cell Count and DECREASED PROTEIN or ELEVATED PROTEIN

ELEVATED PROTEIN CORRECT. CSF results for a patient with GB would reveal increased protein levels and a normal cell count.

Which are symptoms of the acute phase of Guillain-Barre syndrome (GBS)? Select all that apply. Edema Inflammation Remyelination Axonal regeneration Peripheral nerve demyelination

Edema Inflammation Peripheral nerve demyelination Rationale: Guillain-Barré syndrome (GBS) is a disorder of the peripheral nervous system. There are three phases of GBS. The first stage is the acute phase. A symptom of this phase is edema. Rationale: A symptom of the first stage, or the acute phase, is inflammation. Rationale: A symptom of the first stage or the acute phase is peripheral nerve demyelination. Test Taking Tips: Do not confuse early and late symptoms.

Which findings are consistent with lumbar puncture results in a patient who has Guillain-Barré syndrome? Select all that apply. Elevated protein levels Normal cell count Moderate bacterial count Excess blood cells Hypocellular

Elevated protein levels Normal cell count

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Respiratory Impairment INCREASED or DECREASED

INCREASED CORRECT. Due to ascending paralysis, the patient with GB is at risk for increased respiratory impairment, which may require intubation and mechanical ventilation assistance. As the paralysis travels up the body and reaches the core and chest wall muscles, respiratory function becomes impaired. For instance, when paralysis reaches the diaphragm, the muscles do not move properly to help inflate and deflate the lungs.

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Level of consciousness and cognitive level IMPAIRED or INTACT

INTACT CORRECT. The client's level of consciousness and cognitive function remain intact throughout the course of the illness despite the physical limitations.

Use of intravenous immunoglobulin (IVIG) therapy for the treatment of Guillain-Barré is thought to have what effect? Shortens recovery time by up to 75% because it blocks macrophage receptor activity Effective for long-term treatment protocols for patients who have long-term disability Helps to promote antibody production Inhibits complement binding

Inhibits complement binding

Using plasmapheresis as a treatment option for Guillain-Barré is beneficial for what reason? It can be done on an outpatient basis, thereby reducing the need for hospitalization. It shortens length of hospitalization and can prevent the patient from needing mechanical ventilation if implemented in the first week of symptom presentation. It is cost effective because it doesn't require skilled nursing staff for administration. It carries no complications as it is not an invasive procedure.

It shortens length of hospitalization and can prevent the patient from needing mechanical ventilation if implemented in the first week of symptom presentation.

The nurse is reviewing the pathophysiology of neurological conditions. Which disease is demonstrated by this image? Myasthenia gravis Parkinson's disease Guillain-Barré syndrome Trigeminal neuralgia

Myasthenia gravis Rationale: In MG, circulating anti-acetylcholine receptor antibodies bind with the AchR, resulting in complement-mediated destruction of receptor sites.

A patient is diagnosed with myasthenia gravis (MG). The patient also has paralytic ileus and is unable to take oral medication. Which medication is most likely to benefit the patient? Neostigmine Azathioprine Cyclosporine Mycophenolate mofetil

Neostigmine Rationale: Neostigmine is a shorter-acting acetylcholinesterase inhibitor. This medication is administered IV when the oral route is not available because of surgery or other conditions such as Crohn's disease, gastrointestinal bleeding, or paralytic ileus. Test Taking Tips: The nurse must understand medications.

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Initial progression SYMMETRICAL ASCENDING MOTOR WEAKNESS or SYMMETRICAL DESCENDING MOTOR WEAKNESS

SYMMETRICAL ASCENDING MOTOR WEAKNESS CORRECT. The client with GBS develops symmetrical ascending motor weakness and paralysis that usually starts in the feet and extends to the trunk and arms. When the condition improves, symptoms usually first disappear from the trunk and arms before descending.

Which statement is accurate with regard to stages of Guillain-Barré syndrome (GBS)? Each stage lasts approximately 4 weeks. The plateau stage can last from a few days to a few weeks. The acute stage lasts for 48 to 72 hours. Four stages are seen in GBS clients, with the recovery stage lasting the shortest amount of time.

The plateau stage can last from a few days to a few weeks.

This or That? For each option, select the correct assessment or test result for a patient who has been diagnosed with Guillain-Barré syndrome (GB) and is exhibiting clinical symptoms of paralysis. Cranial nerve involvement VII or II

VII CORRECT. Cranial nerve VII (facial nerve) is most commonly affected, and the patient may have difficulty with facial expressions. Additionally, cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal) may also be involved, causing dysphagia