Question 1

A patient with Bell's palsy has lost 10 pounds since being diagnosed. Why is this patient at risk for nutrition problems?

Accepted Answer

Bell's palsy can affect the facial muscles, making it difficult to chew and taste food, which can lead to nutritional problems and weight loss.

Question 2

What nursing diagnosis takes priority when planning care for a patient with trigeminal neuralgia?

Accepted Answer

The priority nursing diagnosis for a patient with trigeminal neuralgia is pain related to inflammation of cranial nerve V. The excruciating pain associated with trigeminal neuralgia can be debilitating and affect the patient's quality of life, therefore managing pain is the priority. Imbalanced nutrition, self-care deficit, and ineffective coping may also be addressed, but they are not the priority in this case.

Question 3

The nurse is caring for a patient admitted with an exacerbation of multiple sclerosis (MS). Which of the following assessment findings should the nurse include when teaching the patient about risk factors for exacerbation?

Accepted Answer

Urinary tract infections are a common trigger for exacerbations in patients with MS because they can cause an increase in body temperature, which can worsen MS symptoms. Exposure to sun, a sedentary lifestyle, and a vegetarian diet are not proven risk factors for exacerbation in MS patients.

Question 4

The nurse is preparing a patient with myasthenia gravis to undergo plasmapheresis. Which laboratory tests should the nurse verify and place on the medical record before the procedure?

Accepted Answer

Plasmapheresis can affect blood components, so it's important to verify complete blood count, platelets, and clotting studies to ensure the patient can safely undergo the procedure.

Question 5

The nurse is caring for a mother of three young children who has a 3-year history of myasthenia gravis. She says to the nurse, "I just wish I could keep helping in my children's classrooms in the mornings. I get so fatigued, I have had to stop going." Which statement by the nurse can help this mother best cope with her problem?

Accepted Answer

Timing the medication so that its action is peaking during the time the mother is helping in the classroom can help improve her energy level and ability to participate in her children's activities. This approach is more proactive and empowering for the mother than simply accepting her limitations or relying on sleep to improve her stamina.

Question 6

A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. What intervention would be most appropriate for this patient?

Accepted Answer

Trigeminal neuralgia causes severe pain in the face, particularly with movements such as chewing. Providing soft foods at body temperature can reduce aggravation of the condition and decrease the pain experienced by the patient. Providing a fan, frequent mouth care, or tissues would not directly address the patient's trigeminal neuralgia symptoms.

Question 7

The nurse is providing care for a patient who has Guillain-Barré syndrome. Which of the following laboratory results should the nurse evaluate first?

Accepted Answer

Arterial blood gases (ABGs) should be evaluated first in a patient with Guillain-Barré syndrome because the disorder can progress to affect the muscles that control breathing, leading to respiratory failure. ABGs can provide critical information about the patient's respiratory status and the need for respiratory support.

Question 8

The nurse is assisting with teaching a patient who is beginning therapy with neostigmine (Prostigmin) for newly diagnosed myasthenia gravis (MG). The patient asks, "How does that work?" What is the best response by the nurse?

Accepted Answer

Neostigmine works by inhibiting the enzyme acetylcholinesterase, which in turn increases the amount of acetylcholine available at the neuromuscular junction. This allows for better transmission of signals from the nerves to the muscles, improving muscle contraction in patients with MG.

Question 9

The nurse is caring for a patient who is being tested for possible myasthenia gravis (MG). What are the most common early symptoms of myasthenia gravis that the nurse should document in the medical record? (Select all that apply.?

Accepted Answer

The most common early symptoms of myasthenia gravis are weakness and ptosis (drooping eyelids). Nausea, numbness of the extremities, confusion, and tremors are not typically associated with MG.

Question 10

A thymectomy is sometimes used to treat which peripheral nervous system disorder?

Accepted Answer

Thymectomy is a surgical procedure to remove the thymus gland, and is often used as a treatment option for myasthenia gravis (MG), an autoimmune disorder that affects the neuromuscular junction and causes muscle weakness and fatigue. Removing the thymus gland can reduce the production of abnormal antibodies that attack the neuromuscular junction, and may improve symptoms in some patients with MG. Thymectomy is not typically used to treat other peripheral nervous system disorders such as multiple sclerosis, Guillain-Barré syndrome, or amyotrophic lateral sclerosis.

Question 11

The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). The nurse recognizes that symptoms of MS are caused by which of the following pathophysiological changes?

Accepted Answer

MS is characterized by demyelination and destruction of nerve fibers in the central nervous system, which leads to a variety of symptoms depending on the location and extent of the damage. Myelin buildup (choice A) is not a characteristic finding in MS. GABA deficiency (choice B) and reduced acetylcholine receptors with impaired nerve impulse transmission (choice C) are not specifically associated with MS.

Question 12

The nurse is helping a patient with trigeminal neuralgia with bathing. Which of the following nursing actions is most important when washing the patient's face?

Accepted Answer

Using lukewarm water and cotton balls is the best choice because it is gentle and less likely to trigger the patient's trigeminal nerve pain. Hot and cold water can both exacerbate the pain, and using a washcloth can be too rough on the sensitive skin of the face. Antibacterial soap is also not necessary for routine face washing.

Question 13

A patient diagnosed with Bell's palsy has all of the following symptoms. Which symptom should the nurse attend to first?

Accepted Answer

Inability to close the affected eye can lead to corneal abrasions and dry eyes which can cause significant discomfort and potential complications. Therefore, it is important for the nurse to attend to this symptom first. The other symptoms may also require attention, but they are not as urgent as protecting the eye.

Question 14

The nurse is assisting with discharging a patient with myasthenia gravis after hospitalization for severe respiratory distress. Which statement by the patient indicates that the nurse's discharge teaching has been effective?

Accepted Answer

Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction and can cause muscle weakness, including respiratory muscles. Prostigmin is a medication that helps improve muscle strength in patients with myasthenia gravis. It is important for patients to take Prostigmin exactly as prescribed, without skipping a dose, to maintain muscle strength and prevent respiratory distress. Anticholinergic medications are not typically used in the treatment of myasthenia gravis, and quinine is not an appropriate medication for muscle cramping in this patient population.

Question 15

The nurse is caring for a patient who has amyotrophic lateral sclerosis. The patient has difficulty swallowing and has copious pulmonary secretions. What equipment is most important to have at the bedside at all times?

Accepted Answer

Suction equipment is crucial for a patient with amyotrophic lateral sclerosis (ALS) who has difficulty swallowing and copious pulmonary secretions, as it helps to clear the airway and prevent aspiration.

Question 16

A patient has been extremely fatigued for the past 2 months and is having difficulty lifting even light objects at work. The physician suspects myasthenia gravis (MG) and asks the nurse to assist with a Tensilon test. What patient response to the Tensilon test leads the nurse to suspect myasthenia gravis?

Accepted Answer

The Tensilon test involves administering edrophonium, a short-acting cholinesterase inhibitor, to the patient and observing for improvement in muscle strength and function. In patients with myasthenia gravis, there is a temporary improvement in ptosis (drooping eyelids) and/or muscle weakness after the administration of edrophonium. Therefore, if the patient's ptosis is temporarily improved after the Tensilon test, the nurse should suspect myasthenia gravis. Dyspnea, muscle weakness, and cramps are not specific to myasthenia gravis and may not necessarily be observed during the Tensilon test.

Question 17

The nurse is assisting with admission of a patient with Guillain-Barré syndrome (GBS) to a medical unit. The patient's legs are weak, making it impossible to walk without assistance. The patient says, "How did I get this? I'm not usually sick." Which response by the nurse is most accurate?

Accepted Answer

GBS is believed to be an autoimmune reaction to a virus, most commonly the flu or Campylobacter bacteria. It is not usually hereditary or caused by a bacterial infection, and while the exact cause is unknown, the autoimmune response theory is currently the most widely accepted explanation.

Question 18

Which drug therapy does the nurse anticipate administering to help resolve an exacerbation of multiple sclerosis?

Accepted Answer

Adrenocorticotropic hormone (ACTH) is a drug therapy commonly used to help resolve exacerbations of multiple sclerosis. It works by reducing inflammation in the brain and spinal cord. Pyridostigmine (Mestinon) is used to treat myasthenia gravis, not multiple sclerosis. Thyrotropin is used to diagnose and treat thyroid disorders, not multiple sclerosis. Diphenhydramine (Benadryl) is an antihistamine used to treat allergies and may have some mild sedative effects, but it is not typically used to treat multiple sclerosis exacerbations.

Question 19

The nurse is assisting with care of a resident diagnosed with amyotrophic lateral sclerosis (ALS). Which assessment findings does the nurse anticipate? (Select all that apply.?

Accepted Answer

The answer of The nurse is assisting with care of...

Question 20

The nurse is providing eye care for a patient with Bell's palsy. Which of the following nursing actions is most appropriate to help protect the affected eye?

Accepted Answer

Requesting an order for ointment and a patch is the most appropriate action to protect the affected eye in Bell's palsy as it will prevent drying of the cornea and provide mechanical protection. Applying a warm moist compress can help reduce pain and inflammation, but it does not provide protection. Keeping the room lights dim is not necessary to protect the eye. Checking for pupil response is important overall, but it does not specifically protect the affected eye.

Quiz 50: Nursing Care of Patients With Peripheral Nervous System Disorders