Nokea
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?
- A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
- B. Flexor spasm, clonus, and negative Babinski's reflex
- C. Blurred vision, intention tremor, and urinary hesitancy
- D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Correct Answer: C
Rationale: Blurred vision (optic neuritis), intention tremor, and urinary hesitancy are typical MS symptoms due to demyelination. Deep tendon reflexes are hyperactive, Babinski's is positive, and abdominal reflexes are absent in MS.
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A patient with Guillain-Barr?© syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?
- A. Administer bronchodilators as ordered.
- B. Remind the patient of the importance of deep breathing and coughing exercises.
- C. Prepare to assist with intubation.
- D. Administer supplementary oxygen by nasal cannula.
Correct Answer: C
Rationale: A sharp decline in vital capacity in Guillain-Barr?© syndrome indicates respiratory muscle weakness, necessitating preparation for intubation to ensure adequate oxygenation. Bronchodilators and oxygen are insufficient, and breathing exercises may be impossible.
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 patient's care plan?
- A. Encourage patient to void every hour.
- B. Order a low-residue diet.
- C. Provide total assistance with all ADLs.
- D. Instruct the patient on daily muscle stretching.
Correct Answer: D
Rationale: Daily muscle stretching helps manage spasticity in MS. Voiding every 30 minutes after drinking, high-fiber diets, and encouraging independence in ADLs are more appropriate.
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?
- A. Cerebral angiography
- B. ABG analysis
- C. CT
- D. EEG
Correct Answer: D
Rationale: EEG shows a characteristic pattern in CJD, aiding diagnosis. CT may rule out other conditions, but angiography and ABGs are not diagnostic for CJD.
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?
- A. Tegretol is not known to have serious adverse effects.
- B. The patient should be monitored for bone marrow depression.
- C. Side effects of the medication include renal dysfunction.
- D. The medication should be first taken in the maximum dosage form to be effective.
Correct Answer: B
Rationale: Carbamazepine can cause bone marrow depression, requiring monitoring. It has serious side effects like aplastic anemia, not renal dysfunction, and is started at a low dose, gradually increased.
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 nurse's best response?
- A. Guillain-Barr?© spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.
- B. In Guillain-Barr?©, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible.
- C. I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question.
- D. For some reason, in Guillain-Barr?©, Schwann cells become activated and take over the remyelination process.
Correct Answer: A
Rationale: Guillain-Barr?© spares Schwann cells, enabling remyelination during recovery. Schwann cells do not replicate preemptively or take over uniquely, and deferring entirely to the physician dismisses the nurse's role.