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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.
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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 patient diagnosed with Bell's palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles?
- A. Blowing up balloons
- B. Deliberately frowning
- C. Smiling repeatedly
- D. Whistling
Correct Answer: D
Rationale: Whistling, along with other facial exercises like wrinkling the forehead, prevents muscle atrophy in Bell's palsy. Blowing balloons, frowning, and smiling are less effective.
A patient diagnosed with myasthenia gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with myasthenia gravis is what?
- A. Every day for 1 week
- B. Determined by the patient's response
- C. Alternate days for 10 days
- D. Determined by the patient's weight
Correct Answer: B
Rationale: Plasmapheresis frequency in myasthenia gravis depends on clinical response, typically daily or alternate days until improvement. Fixed schedules or weight-based dosing are not standard.
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.