Nokea
The nurse is teaching a patient with Guillain-Barr?© syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response?
- A. Guillain-Barr?© spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.
- B. In Guillain-Barr?©, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible.
- C. I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question.
- D. For some reason, in Guillain-Barr?©, Schwann cells become activated and take over the remyelination process.
Correct Answer: A
Rationale: Guillain-Barr?© spares Schwann cells, enabling remyelination during recovery. Schwann cells do not replicate preemptively or take over uniquely, and deferring entirely to the physician dismisses the nurse's role.
You may also like to solve these questions
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.
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.
To alleviate pain associated with trigeminal neuralgia, a patient is taking Tegretol (carbamazepine). What health education should the nurse provide to the patient before initiating this treatment?
- A. Concurrent use of calcium supplements is contraindicated.
- B. Blood levels of the drug must be monitored.
- C. The drug is likely to cause hyperactivity and agitation.
- D. Tegretol can cause tinnitus during the first few days of treatment.
Correct Answer: B
Rationale: Carbamazepine requires monitoring of blood levels to ensure therapeutic efficacy and avoid toxicity. It does not cause hyperactivity or tinnitus, and calcium supplements are not contraindicated.
The nurse is creating a plan of care for a patient who has a recent diagnosis of MS. Which of the following should the nurse include in the patient's care plan?
- A. Encourage patient to void every hour.
- B. Order a low-residue diet.
- C. Provide total assistance with all ADLs.
- D. Instruct the patient on daily muscle stretching.
Correct Answer: D
Rationale: Daily muscle stretching helps manage spasticity in MS. Voiding every 30 minutes after drinking, high-fiber diets, and encouraging independence in ADLs are more appropriate.
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.