MS3, Exam 3, Ch. 60: - Trigeminal neuralgia, Bell's palsy, Guillain-Barre, Tetanus, Botulism

The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."

1. "You should make a full recovery within a few months to a year." Clients with this syndrome usually have a full recovery, but it may take up to one (1) year.

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.

1. Assess deep tendon reflexes. Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate.

The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect? 1. Bell's palsy. 2. Right-sided stroke. 3. Tetany. 4. Mononeuropathy.

1. Bell's palsy. Bell's palsy, called facial paralysis, is a disorder of the 7th cranial nerve (facial nerve) characterized by unilateral paralysis of facial muscles.

Which should be the nurse's first intervention with the client diagnosed with Bell's palsy? 1. Explain that this disorder will resolve within a month. 2. Tell the client to apply heat to the involved side of the face. 3. Encourage the client to eat a soft diet. 4. Teach the client to protect the affected eye from injury.

4. Teach the client to protect the affected eye from injury. Teaching the client to protect the eye is a priority because the eye does not close completely and the blink reflex is diminished, making the eye vulnerable to injury. The client should wear an eye patch at night and wraparound sunglasses or goggles during the day; he or she may also need artificial tears.

The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply. 1. Refer the client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation.

1. Refer the client to the physical therapist. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation. The physical therapist is an important part of the rehabilitation team who addresses the client's muscle deterioration resulting from the disease process and immobility. The social worker could help with financial concerns, job issues, and issues concerning the long rehabilitation time for this syndrome. Pain may or may not be an issue with this syndrome. Each client is different, but a plan needs to be established to address pain if it occurs. This is an excellent resource for the client and the family.

Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."

2. "I had a really bad cold just a few weeks ago." This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits.

The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help to prevent DVTs by movement of the blood through the veins.

4. They help to prevent DVTs by movement of the blood through the veins. One reason for performing range-of-motion exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT.

The client presents to the ED with acute vomiting after eating at a fast-food restaurant. There has not been any diarrhea. The nurse suspects botulism poisoning. Which nursing problem is the highest priority for this client? 1. Fluid volume loss. 2. Risk for respiratory paralysis. 3. Abdominal pain. 4. Anxiety.

2. Risk for respiratory paralysis. Clients with botulism are at risk for respiratory paralysis, and this is the priority problem.

The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.

2. The client will have no muscle atrophy. The client with Guillain-Barré syndrome will not be able to move the extremities; therefore, preventing muscle atrophy is an appropriate long-term goal.

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on. 2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.

2. Instruct the client to blink once for "no" and twice for "yes." The client will not be able to use the arms as a result of the paralysis but can blink the eyes as long as the nurse asks simple "yes-or-no" questions.

The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority? 1. Keep the client NPO. 2. Instruct the client to void. 3. Place in the lithotomy position. 4. Assess the client's pedal pulse.

2. Instruct the client to void. The client should void prior to this procedure to help prevent accidental puncture of the bladder during the procedure.

The male client comes to the emergency department and reports he stepped on a rusty nail at home about two (2) hours ago. Which question would be most important for the nurse to ask during the admission assessment? 1. "What have you used to clean the puncture site?" 2. "Did you bring the nail with you so we can culture it?" 3. "Do you remember when you had your last tetanus shot?" 4. "Are you able to put any weight on your foot?"

3. "Do you remember when you had your last tetanus shot?" The tetanus shot must be received every 10 years to prevent tetany, also known as "lockjaw."

Which medication should the nurse expect the HCP to order to treat the client diagnosed with botulism secondary to eating contaminated canned goods? 1. An antidiarrheal medication. 2. An aminoglycoside antibiotic. 3. An antitoxin medication. 4. An ACE inhibitor medication.

3. An antitoxin medication. A botulism antitoxin neutralizes the circulating toxin and is prescribed for a client with botulism.

The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client? 1. Joint pain of the neck and jaw. 2. Unconscious grinding of the teeth during sleep. 3. Sudden severe unilateral facial pain. 4. Progressive loss of calcium in the nasal septum.

3. Sudden severe unilateral facial pain. Trigeminal neuralgia affects the 5th cranial nerve and is characterized by paroxysms of pain in the area innervated by the three branches of the nerve. The unilateral nature of the pain is an important diagnostic characteristic. The disorder is also known as tic douloureux.

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.4, Pao2 88, Paco2 35, and Hco3 24.

3. The client's pulse oximeter reading is 85%. A pulse oximeter reading of less than 93% warrants immediate intervention; a 90% peripheral oxygen saturation indicates a Pao2 of about 60 (normal, 80 to 100). When the client is placed on the ventilator, this should cause the client's oxygen level to improve.

The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement? 1. Tell the wife she must stop crying. 2. Escort the wife out of the room. 3. Medicate the client immediately. 4. Acknowledge the wife's fears.

4. Acknowledge the wife's fears. It is scary for a wife to see her loved one with a tube down his mouth and all the machines around him. The nurse should help the wife by acknowledging her fears.

The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client? 1. Assess the client's sense of smell and taste. 2. Teach the client how to care for the eyes. 3. Instruct the client to have carbamazepine (Tegretol) levels monitored regularly. 4. Assist the client to identify factors that trigger an attack.

4. Assist the client to identify factors that trigger an attack. Stimulating specific areas of the face, called trigger zones, many initiate the onset of pain. Therefore, the nurse should help the client identify situations that exacerbate the condition, such as chewing gum, eating, brushing the teeth, or being exposed to a draft of cold air.

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4. Progressive ascending paralysis of the lower extremities and numbness. Ascending paralysis is the classic symptom of Guillain-Barré syndrome.

The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure? 1. Monitor the client for hypotension. 2. Apply pressure to the puncture site. 3. Test the client's cerebrospinal fluid. 4. Increase the client's fluid intake.

4. Increase the client's fluid intake. Increased fluid intake will help prevent a postprocedure headache, which may occur after a lumbar puncture.

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.

4. Ineffective breathing pattern. Guillain-Barré syndrome has ascending paralysis causing respiratory failure. Therefore, breathing pattern is priority.