Nokea
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.
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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.
A patient with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine (Tegretol) for pain relief. What principle applies to the administration of this medication?
- A. Tegretol is not known to have serious adverse effects.
- B. The patient should be monitored for bone marrow depression.
- C. Side effects of the medication include renal dysfunction.
- D. The medication should be first taken in the maximum dosage form to be effective.
Correct Answer: B
Rationale: Carbamazepine can cause bone marrow depression, requiring monitoring. It has serious side effects like aplastic anemia, not renal dysfunction, and is started at a low dose, gradually increased.
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 middle-aged woman has sought care from her primary care provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care?
- A. Cognitive declines
- B. Personality changes
- C. Contractures
- D. Difficulty in coordination
Correct Answer: D
Rationale: Difficulty in coordination, along with fatigue and weakness, is a common early symptom of MS prompting medical evaluation. Cognitive declines and contractures occur later, and personality changes are not typical.
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.