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A patient with Guillain-Barr?© syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?
- A. Administer bronchodilators as ordered.
- B. Remind the patient of the importance of deep breathing and coughing exercises.
- C. Prepare to assist with intubation.
- D. Administer supplementary oxygen by nasal cannula.
Correct Answer: C
Rationale: A sharp decline in vital capacity in Guillain-Barr?© syndrome indicates respiratory muscle weakness, necessitating preparation for intubation to ensure adequate oxygenation. Bronchodilators and oxygen are insufficient, and breathing exercises may be impossible.
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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.
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?
- A. All at one time, to provide a longer rest period
- B. Before meals, to stimulate her appetite
- C. In the morning, with frequent rest periods
- D. Before bedtime, to promote rest
Correct Answer: C
Rationale: Scheduling procedures in the morning with rest periods minimizes fatigue in myasthenia gravis, where muscle weakness worsens with activity. Other timings risk exhaustion or poor appetite.
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.
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.
A patient with diabetes presents to the clinic and is diagnosed with a mononeuropathy. This patient's nursing care should involve which of the following?
- A. Protection of the affected limb from injury
- B. Passive and active ROM exercises for the affected limb
- C. Education about improvements to glycemic control
- D. Interventions to prevent contractures
Correct Answer: A
Rationale: Mononeuropathy causes sensory loss, requiring protection of the affected limb from injury. ROM exercises, glycemic control education, and contracture prevention are not primary interventions.