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You are the clinic nurse caring for a patient with a recent diagnosis of myasthenia gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?
- A. Increased muscle strength
- B. Decreased pain
- C. Improved GI function
- D. Improved cognition
Correct Answer: A
Rationale: Pyridostigmine enhances muscle strength in myasthenia gravis by inhibiting acetylcholine breakdown. It does not target pain, GI function, or cognition.
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A patient is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority?
- A. Serial assessments of hemoglobin levels
- B. Blood glucose monitoring
- C. Close monitoring of fluid balance
- D. Assessment of pain along dermatomes
Correct Answer: C
Rationale: St. Louis encephalitis is associated with SIADH, causing hyponatremia, so monitoring fluid balance is critical. Hemoglobin, glucose, and dermatomal pain are not specific to this condition.
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.
A 73-year-old man comes to the clinic complaining of weakness and loss of sensation in his feet and legs. Assessment of the patient shows decreased reflexes bilaterally. Why would it be a challenge to diagnose a peripheral neuropathy in this patient?
- A. Older adults are often vague historians.
- B. The elderly have fewer peripheral nerves than younger adults.
- C. Many older adults are hesitant to admit that their body is changing.
- D. Many symptoms can be the result of normal aging process.
Correct Answer: D
Rationale: Symptoms like decreased reflexes in peripheral neuropathy can mimic normal aging, complicating diagnosis. Older adults do not necessarily have fewer nerves or withhold information.
A patient is being admitted through the ED with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient's complaints of headache?
- A. Initiating a patient-controlled analgesia (PCA) of morphine sulfate
- B. Administering hydromorphone (Dilaudid) IV as needed
- C. Dimming the lights and reducing stimulation
- D. Distracting the patient with activity
Correct Answer: C
Rationale: Dimming lights and reducing stimulation alleviate headache in herpes simplex virus encephalitis by minimizing sensory overload. Opioids may mask neurologic symptoms, and distraction is ineffective.
The nurse caring for a patient in ICU diagnosed with Guillain-Barr?© syndrome should prioritize monitoring for what potential complication?
- A. Impaired skin integrity
- B. Cognitive deficits
- C. Hemorrhage
- D. Autonomic dysfunction
Correct Answer: D
Rationale: Autonomic dysfunction, causing issues like heart rate variability, is a critical complication in Guillain-Barr?© syndrome. Skin integrity is a concern but less urgent, and cognitive deficits or hemorrhage are not typical.