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The nurse is caring for a patient who has onset Guillain-Barré syndrome. During this phase of the patient's illness, which of the following parameters is the most important for the nurse to assess?
- A. Monitor the cardiac rhythm.
- B. Determine level of consciousness.
- C. Check strength of the extremities.
- D. Observe respiratory rate and effort.
Correct Answer: D
Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments also will be included in nursing care, but they are not as important as respiratory assessment.
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In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department?
- A. Infuse normal saline at 150 mL/hour.
- B. Monitor cardiac rhythm and blood pressure.
- C. Administer O2 using a non-rebreather mask.
- D. Transfer the patient to radiology for spinal computed tomography (CT).
- E. Immobilize the patient's head, neck, and spine.
Correct Answer: E,C,B,A,D
Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
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.
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 nurse is assessing a patient with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
- A. Triggers that lead to facial pain
- B. Visual problems caused by ptosis
- C. Poor appetite caused by a loss of taste
- D. Weakness on the affected side of the face
Correct Answer: A
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
The nurse is caring for a patient with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
- A. Ask whether the patient is using an eye shield at night.
- B. Determine whether the patient is doing daily facial exercises.
- C. Question the patient about social activities with family and friends.
- D. Remind the patient to chew food on the unaffected side of the mouth.
Correct Answer: C
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.