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A patient is being admitted through the ED with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache?
- A. Initiating a patient-controlled analgesia (PCA) of morphine sulfate
- B. Administering hydromorphone (Dilaudid) IV as needed
- C. Dimming the lights and reducing stimulation
- D. Distracting the patient with activity
Correct Answer: C
Rationale: Dimming lights and reducing stimulation alleviate headache in herpes simplex virus encephalitis by minimizing sensory overload. Opioids may mask neurologic symptoms, and distraction is ineffective.
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A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what?
- A. Every day for 1 week
- B. Determined by the patient's response
- C. Alternate days for 10 days
- D. Determined by the patient's weight
Correct Answer: B
Rationale: Plasmapheresis frequency in myasthenia gravis depends on clinical response, typically daily or alternate days until improvement. Fixed schedules or weight-based dosing are not standard.
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 MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
- A. Establish a timed voiding schedule.
- B. Avoid foods that change the pH of urine.
- C. Perform intermittent catheterization q6h.
- D. Administer anticholinergic drugs as ordered.
Correct Answer: A
Rationale: A timed voiding schedule promotes bladder control in MS by training the bladder. Catheterization and anticholinergics are not first-line, and urine pH is irrelevant.
The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
- A. Genetic dysfunction
- B. Upper and lower motor neuron lesions
- C. Decreased conduction of impulses in an upper motor neuron lesion
- D. A lower motor neuron lesion
Correct Answer: D
Rationale: Myasthenia gravis results from a lower motor neuron lesion at the myoneural junction, causing muscle weakness. It is not genetic, nor does it involve upper motor neurons.
The nurse is developing a plan of care for a patient with Guillain-Barr?© syndrome. Which of the following interventions should the nurse prioritize for this patient?
- A. Using the incentive spirometer as prescribed
- B. Maintaining the patient on bed rest
- C. Providing aids to compensate for loss of vision
- D. Assessing frequently for loss of cognitive function
Correct Answer: A
Rationale: Incentive spirometry maximizes respiratory function, critical in Guillain-Barr?© due to potential respiratory muscle weakness. Bed rest increases complications, and vision or cognition are not typically affected.