A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
a) Lung auscultation and measurement of vital capacity and tidal volume
b) Evaluation of pain and discomfort
c) Evaluation of nutritional status and metabolic state
d) Evaluation for signs and symptoms of increased intracranial pressure (ICP)
Answer: Lung auscultation and measurement of vital capacity and tidal volume
Autoimmune Disorders
- Bell's palsy is a disorder of which cranial nerve?
- The primary North American vector transmitting arthropod-borne virus encephalitis is the
- Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
- Which of the following is the priority nursing intervention for a patient in myasthenic crisis?
- The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
- The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
- The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
- A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
- A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
- A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
- A patient has been diagnosed with a frontal lobe brain abscess. Which of the following nursing interventions is appropriate?
- During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
- The diagnosis of multiple sclerosis is based on which of the following tests?
- The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- The diagnosis of multiple sclerosis is based upon which of the following tests?
- Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?
- Which of the following is the most common clinical manifestation of multiple sclerosis?
- A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
- A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for
- The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?
- Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)?
Neurologic Infections
- Bell's palsy is a disorder of which cranial nerve?
- The primary North American vector transmitting arthropod-borne virus encephalitis is the
- Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
- Which of the following is the priority nursing intervention for a patient in myasthenic crisis?
- The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
- The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
- The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
- A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
- A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
- A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
- A patient has been diagnosed with a frontal lobe brain abscess. Which of the following nursing interventions is appropriate?
- During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
- The diagnosis of multiple sclerosis is based on which of the following tests?
- The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- The diagnosis of multiple sclerosis is based upon which of the following tests?
- Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?
- Which of the following is the most common clinical manifestation of multiple sclerosis?
- A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
- A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for
- The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?
- Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)?
Neuropathies
- Bell's palsy is a disorder of which cranial nerve?
- The primary North American vector transmitting arthropod-borne virus encephalitis is the
- Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord?
- Which of the following is the priority nursing intervention for a patient in myasthenic crisis?
- The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication?
- The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?
- The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis?
- A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
- A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease?
- A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include?
- A patient has been diagnosed with a frontal lobe brain abscess. Which of the following nursing interventions is appropriate?
- During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?
- The diagnosis of multiple sclerosis is based on which of the following tests?
- The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- The diagnosis of multiple sclerosis is based upon which of the following tests?
- Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, is manifested by which of the following?
- Which of the following is the most common clinical manifestation of multiple sclerosis?
- A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications?
- A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?
- Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
- Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for
- The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction?
- Which of the following is a component of the nursing management of the patient with new variant Creutzfeldt-Jakob disease (nvCJD)?