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The nurse is caring for a patient hospitalized with Guillain-Barré syndrome who has numbness and weakness in both feet. Which of the following information should the nurse include in the patient's plan of care?
- A. Intubation and mechanical ventilation
- B. Administration of IV corticosteroid drugs
- C. Insertion of a nasogastric (NG) feeding tube
- D. IV infusion of high dose immunoglobulin (IVIG)
Correct Answer: D
Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.
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The nurse is admitting a patient with a spinal cord injury. Which of the following collaborative and nursing actions should the nurse do immediately? (Select all that apply.)
- A. Stabilize spine with sand bags
- B. Nasogastric (NG) tube feeding
- C. Ensure patency of airway
- D. Avoidance of cool room temperature
- E. Insert Foley catheter
Correct Answer: A,C,E
Rationale: Immediate care for a patient with a spinal cord injury is to ensure a patent airway, stabilize the spine with a hard collar or sand bags, and insert a Foley catheter. Avoidance of a cool room temperature is not part of immediate care. A tube feeding would not be initiated in the immediate postinjury care period.
The nurse is teaching a patient who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?
- A. Call the doctor if pain or herpes lesions occur near the ear.
- B. Treatment of herpes with antiviral agents prevents Bell's palsy.
- C. You may be able to prevent Bell's palsy by doing facial exercises regularly.
- D. Medications to treat Bell's palsy work only if started before paralysis onset.
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
The nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury. Which of the following goals should the nurse include for this patient?
- A. Transfer independently to a wheelchair.
- B. Drive a car with powered hand controls.
- C. Turn and reposition independently when in bed.
- D. Push a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
The nurse is facilitating a bladder training program for a patient who had a spinal cord injury 2 weeks ago and is stable. Which of the following amounts of daily fluid should the nurse include in the patient plan of care to maintain the patient on fluid restriction?
- A. 600-800 mL
- B. 1000-1200 mL
- C. 1400-1600 mL
- D. 1800-2000 mL
Correct Answer: D
Rationale: Many patients are maintained on fluid restriction of 1800-2000 mL/day to facilitate a bladder training program, and urinary output is monitored closely.
The health care provider prescribes these interventions for a patient with possible botulism poisoning. Which of the following prescriptions should the nurse question?
- A. Maintain NPO status.
- B. Obtain lumbar puncture tray.
- C. Give magnesium citrate 240 mL stat.
- D. Administer 1500 mL tap water enema.
Correct Answer: C
Rationale: Magnesium is contraindicated because it may worsen the neuromuscular blockade. The other orders are appropriate for the patient.