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The nurse is developing a plan of care for a patient with Guillain-Barr?© syndrome. Which of the following interventions should the nurse prioritize for this patient?
- A. Using the incentive spirometer as prescribed
- B. Maintaining the patient on bed rest
- C. Providing aids to compensate for loss of vision
- D. Assessing frequently for loss of cognitive function
Correct Answer: A
Rationale: Incentive spirometry maximizes respiratory function, critical in Guillain-Barr?© due to potential respiratory muscle weakness. Bed rest increases complications, and vision or cognition are not typically affected.
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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 planning discharge education for a patient with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the patient to avoid?
- A. Washing his face
- B. Exposing his skin to sunlight
- C. Using artificial tears
- D. Drinking large amounts of fluids
Correct Answer: A
Rationale: Washing the face can trigger pain in trigeminal neuralgia due to stimulation of the affected nerve. Sunlight exposure, artificial tears, and fluid intake do not typically precipitate attacks.
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?
- A. All at one time, to provide a longer rest period
- B. Before meals, to stimulate her appetite
- C. In the morning, with frequent rest periods
- D. Before bedtime, to promote rest
Correct Answer: C
Rationale: Scheduling procedures in the morning with rest periods minimizes fatigue in myasthenia gravis, where muscle weakness worsens with activity. Other timings risk exhaustion or poor appetite.
A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
- A. Establish a timed voiding schedule.
- B. Avoid foods that change the pH of urine.
- C. Perform intermittent catheterization q6h.
- D. Administer anticholinergic drugs as ordered.
Correct Answer: A
Rationale: A timed voiding schedule promotes bladder control in MS by training the bladder. Catheterization and anticholinergics are not first-line, and urine pH is irrelevant.
A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?
- A. Guillain-Barr?© syndrome
- B. Myasthenia gravis
- C. Trigeminal neuralgia
- D. Peripheral nerve disorder
Correct Answer: D
Rationale: Pain, weakness, diminished reflexes, and sensory loss in the extremities indicate a peripheral nerve disorder. Guillain-Barr?© involves ascending paralysis, myasthenia gravis affects voluntary muscles, and trigeminal neuralgia causes facial pain.