Nokea
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?
- A. The patient will likely require lifelong treatment with anticholinergic medications.
- B. The patient has a disproportionate risk of developing myasthenia gravis later in life.
- C. The patient needs to be assessed for MS.
- D. The disease is self-limiting and the patient will achieve pain relief over time.
Correct Answer: C
Rationale: Trigeminal neuralgia in patients under 50 may indicate MS, necessitating evaluation. It is not treated with anticholinergics, not linked to myasthenia gravis, and not self-limiting.
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The critical care nurse is caring for a 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this patient?
- A. Maintaining the patient's functional independence
- B. Providing health education
- C. Monitoring neurologic status closely
- D. Promoting mobility
Correct Answer: C
Rationale: Close neurologic monitoring is critical for brain abscess patients to detect changes like increased intracranial pressure. Independence, education, and mobility are secondary in acute care.
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 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?
- A. Reduction in the appearance of new lesions on the MRI
- B. Decreased muscle spasms in the lower extremities
- C. Increased muscle strength in the upper extremities
- D. Decreased severity and duration of exacerbations
Correct Answer: B
Rationale: Baclofen reduces muscle spasms in MS by acting as a GABA agonist. It does not affect MRI lesions, upper extremity strength, or exacerbation duration.
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?
- A. Cognitive declines
- B. Personality changes
- C. Contractures
- D. Difficulty in coordination
Correct Answer: D
Rationale: Difficulty in coordination, along with fatigue and weakness, is a common early symptom of MS prompting medical evaluation. Cognitive declines and contractures occur later, and personality changes are not typical.
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?
- A. Suctioning secretions
- B. Facilitating ABG analysis
- C. Providing ventilatory assistance
- D. Administering tube feedings
Correct Answer: C
Rationale: Myasthenic crisis causes severe muscle weakness, risking respiratory failure, so ventilatory assistance is the priority. Suctioning, ABGs, and feeding are secondary.