A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is
- a. determining level of consciousness.
- b. checking strength of the extremities.
- c. observing respiratory rate and effort.
- d. monitoring the cardi...
A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most
essential assessment for the nurse to carry out is
- a. determining level of consciousness.
- b. checking strength of the extremities.
- c. observing respiratory rate and effort.
- d. monitoring the cardiac rate and rhythm. - - ANS: C. observing respiratory rate and effort.
- The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse
should monitor respiratory function continuously. The other assessments will also be included in
nursing care, but they are not as important as respiratory assessment.
A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated
with pregnancy. Which response by the nurse is accurate?
- a. MS symptoms may be worse after the pregnancy.
- b. Women with MS frequently have premature labor.
- c. MS is associated with an increased risk for congenital defects.
- d. Symptoms of MS are likely to become worse during pregnancy. - - ANS: A. MS symptoms
may be worse after pregnancy.
- During the postpartum period, women with MS are at greater risk for exacerbation of
symptoms. There is no increased risk for congenital defects in infants born of mothers with MS.
Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.
A 32-year-old pregnant patient with Bells palsy refuses to eat while others are present because
of embarrassment about drooling. The best response by the nurse is to
- a. respect the patients feelings and arrange for privacy at mealtimes.
- b. teach the patient to chew food on the unaffected side of the mouth.
- c. offer the patient liquid nutritional supplements at frequent intervals.
- d. discuss the patients concerns with visitors who arrive at mealtimes. - - ANS: A. respect the
patients feelings and arrange for privacy at mealtimes.
- The patients desire for privacy should be respected to encourage adequate nutrition and
reduce patient embarrassment. Liquid supplements will reduce the patients enjoyment of the
taste of food. It would be inappropriate for the nurse to discuss the patients embarrassment with
visitors unless the patient wishes to share this information. Chewing on the unaffected side of
the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the
patient, spouse, and children about this disorder, the nurse will provide information about the
, - a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
- b. prophylactic antibiotics to decrease the risk for aspiration pneumonia.
- c. option of genetic testing for the patients children to determine their own HD risks.
- d. lifestyle changes of improved nutrition and exercise that delay disease progression. - - ANS:
C. option of genetic testing for the patients children to determine their own HD risks.
- Genetic testing is available to determine whether an asymptomatic individual has the HD gene.
The patient and family should be informed of the benefits and problems associated with genetic
testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine.
Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or
lifestyle changes that delay the progression of symptoms in HD.
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate
(Copaxone). Which information will the nurse include in patient teaching?
- a. Recommendation to drink at least 4 L of fluid daily
- b. Need to avoid driving or operating heavy machinery
- c. How to draw up and administer injections of the medication
- d. Use of contraceptive methods other than oral contraceptives - - ANS: C. How to draw up &
administer injections of the medication
- Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for
birth control. There is no need to avoid driving or drink large fluid volumes when taking
glatiramer.
A 62-year-old patient who has Parkinsons disease is taking bromocriptine (Parlodel). Which
information obtained by the nurse may indicate a need for a decrease in the dose?
- a. The patient has a chronic dry cough.
- b. The patient has four loose stools in a day.
- c. The patient develops a deep vein thrombosis.
- d. The patients blood pressure is 92/52 mm Hg. - - ANS: D. The patients blood pressure is
92/52 mm Hg.
- Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health
care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not
associated with bromocriptine use.
A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with
pneumonia. Which nursing action will be included in the plan of care?
- a. Assist with active range of motion (ROM).
- b. Observe for agitation and paranoia.
- c. Give muscle relaxants as needed to reduce spasms.
- d. Use simple words and phrases to explain procedures. - - ANS: A. Assist with active range of
motion (ROM).
- ALS causes progressive muscle weakness, but assisting the patient to perform active ROM
will help maintain strength as long as possible. Psychotic manifestations such as agitation and
paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the
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