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A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
- A. Ask the client to explain his feelings related to this disorder
- B. Ask how dental hygiene is related to overall health
- C. Tell the client that he will become malnourished in time
- D. Inform the client about dental care options
Correct Answer: A
Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
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The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
- A. Administering anxiolytics
- B. Administering a ventilator
- C. Obtaining atropine sulfate
- D. Sedating the client
Correct Answer: C
Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator may be needed, but emergency equipment should be available.
The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
- A. Delayed afferent nerve impulses
- B. Delayed efferent nerve impulses
- C. Desynthesis in upper extremities
- D. Slows nerve impulse transmission
Correct Answer: D
Rationale: Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assessing the client's gag reflex
- B. Cutting foods up into small bites
- C. Monitoring potassium levels
- D. Weighing the client daily
- E. Thickening liquids to prevent aspiration
Correct Answer: B,D
Rationale: Cutting food up into smaller bites makes it easier for the client to chew and swallow. The UAP can weigh the client daily to monitor nutritional status. Assessing the gag reflex and monitoring potassium levels are tasks that require nursing judgment and cannot be delegated to UAP. Thickening liquids is typically a nursing or dietary intervention, not a UAP task.
The nurse caring for a client with Guillain-Barr?© syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
- A. Ask occupational therapy to help the client with activities of daily living
- B. Communicate with physical therapy for a consult
- C. Provide the client with information on support groups
- D. Refer the client to a medical social worker or chaplain
- E. Work with speech therapy to design a high-protein diet
Correct Answer: A,B,E
Rationale: Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy for nutritional support. While support groups, social work, or chaplain referrals may be needed, they do not directly help with mobility.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
- A. Avoid having teeth pulled for 1 year
- B. Avoid heavy lifting for 6 months
- C. Do not use harsh chemicals on your face
- D. Inform your dentist of this procedure
Correct Answer: C
Rationale: The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the affected side to prevent injury. The other instructions are not necessary.