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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.
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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.
The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease?
- A. Tinnitus
- B. Facial paralysis
- C. Pain at the base of the tongue
- D. Diplopia
Correct Answer: B
Rationale: Bell's palsy causes facial paralysis due to cranial nerve VII dysfunction. Tinnitus, tongue pain, and diplopia are not characteristic of this condition.
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient?
- A. Cerebral angiography
- B. ABG analysis
- C. CT
- D. EEG
Correct Answer: D
Rationale: EEG shows a characteristic pattern in CJD, aiding diagnosis. CT may rule out other conditions, but angiography and ABGs are not diagnostic for CJD.
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.
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.