Nokea
A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?
- A. Guillain-Barr?© syndrome
- B. Myasthenia gravis
- C. Trigeminal neuralgia
- D. Peripheral nerve disorder
Correct Answer: D
Rationale: Pain, weakness, diminished reflexes, and sensory loss in the extremities indicate a peripheral nerve disorder. Guillain-Barr?© involves ascending paralysis, myasthenia gravis affects voluntary muscles, and trigeminal neuralgia causes facial pain.
You may also like to solve these questions
A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
- A. Older adults are often vague historians.
- B. The elderly have fewer peripheral nerves than younger adults.
- C. Many older adults are hesitant to admit that their body is changing.
- D. Many symptoms can be the result of normal aging process.
Correct Answer: D
Rationale: Symptoms like decreased reflexes in peripheral neuropathy can mimic normal aging, complicating diagnosis. Older adults do not necessarily have fewer nerves or withhold information.
The nurse is discharging a patient home after surgery for trigeminal neuralgia. What advice should the nurse provide to this patient in order to reduce the risk of injury?
- A. Avoid watching television or using a computer for more than 1 hour at a time.
- B. Use OTC antibiotic eye drops for at least 14 days.
- C. Avoid rubbing the eye on the affected side of the face.
- D. Rinse the eye on the affected side with normal saline daily for 1 week.
Correct Answer: C
Rationale: Surgery may cause sensory loss, making eye rubbing dangerous as pain from injury may not be felt. TV use, antibiotic drops, and saline rinses are not relevant to injury prevention.
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.
The nurse caring for a patient in ICU diagnosed with Guillain-Barr?© syndrome should prioritize monitoring for what potential complication?
- A. Impaired skin integrity
- B. Cognitive deficits
- C. Hemorrhage
- D. Autonomic dysfunction
Correct Answer: D
Rationale: Autonomic dysfunction, causing issues like heart rate variability, is a critical complication in Guillain-Barr?© syndrome. Skin integrity is a concern but less urgent, and cognitive deficits or hemorrhage are not typical.
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment?
- A. Concurrent use of calcium supplements is contraindicated.
- B. Blood levels of the drug must be monitored.
- C. The drug is likely to cause hyperactivity and agitation.
- D. Tegretol can cause tinnitus during the first few days of treatment.
Correct Answer: B
Rationale: Carbamazepine requires monitoring of blood levels to ensure therapeutic efficacy and avoid toxicity. It does not cause hyperactivity or tinnitus, and calcium supplements are not contraindicated.