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The nurse caring for a patient diagnosed with Guillain-Barr?© syndrome is planning care with regard to the clinical manifestations associated with this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease?
- A. Intermittent hearing loss
- B. Tinnitus
- C. Tongue enlargement
- D. Vocal paralysis
Correct Answer: D
Rationale: Guillain-Barr?© syndrome affects the vagus nerve (X), potentially causing vocal paralysis or dysphagia. Hearing loss, tinnitus, and tongue enlargement are not associated.
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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.
A patient with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the physician to order for the treatment of this disease process?
- A. Cyclosporine (Neoral)
- B. Acyclovir (Zovirax)
- C. Cyclobenzaprine (Flexeril)
- D. Ampicillin (Prinicipen)
Correct Answer: B
Rationale: Acyclovir is an antiviral effective against HSV by inhibiting viral DNA replication. Cyclosporine, cyclobenzaprine, and ampicillin do not treat viral infections.
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 is working with a patient who is newly diagnosed with MS. What basic information should the nurse provide to the patient?
- A. MS is a progressive demyelinating disease of the nervous system.
- B. MS usually occurs more frequently in men.
- C. MS typically has an acute onset.
- D. MS is sometimes caused by a bacterial infection.
Correct Answer: A
Rationale: MS is a chronic, progressive demyelinating disease of the central nervous system. It affects women more than men, has a gradual onset, and is not caused by bacterial infection.
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
- A. Arrange for the patient to receive a low residue diet.
- B. Position the patient upright during feeding.
- C. Suction the patient following each meal.
- D. Withhold liquids until the patient has finished eating.
Correct Answer: B
Rationale: Upright positioning during feeding reduces aspiration risk in MS-related dysphagia. Low-residue diets, routine suctioning, and withholding liquids are not indicated.