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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.
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The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed?
- A. Ensure that suction apparatus is set up at the bedside.
- B. Pad the patient's bed rails.
- C. Maintain bed rest whenever possible.
- D. Provide several small meals each day.
Correct Answer: A
Rationale: MS exacerbations increase aspiration risk due to dysphagia, so suction apparatus at the bedside is critical for safety. Bed rest should be minimized, and padding or small meals are not priority.
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.
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 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.
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
- A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
- B. Flexor spasm, clonus, and negative Babinski's reflex
- C. Blurred vision, intention tremor, and urinary hesitancy
- D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Correct Answer: C
Rationale: Blurred vision (optic neuritis), intention tremor, and urinary hesitancy are typical MS symptoms due to demyelination. Deep tendon reflexes are hyperactive, Babinski's is positive, and abdominal reflexes are absent in MS.