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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.
- A. Blood pressure greater than 140/90 mm Hg
- B. Heart rate greater than 120 bpm
- C. Older age
- D. Low Glasgow Coma Scale
- E. Lack of previous immunizations
Correct Answer: B,C,D
Rationale: Older age, tachycardia (>120 bpm), and low Glasgow Coma Scale score indicate severe meningitis and worse outcomes. Hypertension and lack of immunizations are not directly linked to prognosis.
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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.
A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis?
- A. Pain upon ankle dorsiflexion of the foot
- B. Neck flexion produces flexion of knees and hips
- C. Inability to stand with eyes closed and arms extended without swaying
- D. Numbness and tingling in the lower extremities
Correct Answer: B
Rationale: A positive Brudzinski's sign, where neck flexion causes knee and hip flexion, is a hallmark of bacterial meningitis due to meningeal irritation. Pain on dorsiflexion (Homans' sign) relates to thrombosis, Romberg's sign to balance issues, and numbness to peripheral neuropathy, none of which are typical for meningitis.
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?
- A. Increased muscle strength
- B. Decreased pain
- C. Improved GI function
- D. Improved cognition
Correct Answer: A
Rationale: Pyridostigmine enhances muscle strength in myasthenia gravis by inhibiting acetylcholine breakdown. It does not target pain, GI function, or cognition.
A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Bell's palsy can impair eye closure, risking corneal damage, so a protective eye shield at night is essential. Chewing on the affected side is difficult, analgesics may be needed, and oral hygiene should continue.
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.
- A. Possible nursing home placement
- B. Pain associated with physical therapy
- C. Increasing disability
- D. Becoming a burden on the family
- E. Loss of appetite
Correct Answer: A,C,D
Rationale: Elderly MS patients worry about increasing disability, family burden, and potential nursing home placement due to progressive loss of function. Pain from therapy and appetite loss are not primary concerns.