ATI Care of Patients with Problems of the Peripheral Nervous System, Questions and Answers with Explanations, 100% Correct, Download to Score A

Test Bank

MULTIPLE CHOICE

1. The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?

a.            Nerve impulses are not transmitted to skeletal muscle.

b.            The immune system destroys the myelin sheath.

c.             The distal nerves degenerate and retract.

d.            Antibodies to acetylcholine receptor sites develop.

ANS: B

In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 987

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client?

a.            Ophthalmoplegia and diplopia

b.            Progressive weakness without sensory involvement

c.             Progressive, ascending weakness and paresthesia

d.            Weakness of the face, jaw, and sternocleidomastoid muscles

ANS: C

The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barré syndrome.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 987

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process?

a.            Increased cerebrospinal fluid (CSF) protein level

b.            Decreased serum protein electrophoresis results

c.             Increased antinuclear antibodies

d.            Decreased immune globulin G (IgG) levels

ANS: A

A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 988

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client’s vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse’s priority action?

a.            Place the client in a high Fowler’s position.

b.            Prepare the client for elective intubation.

c.             Administer oxygen via a nasal cannula.

d.            Auscultate for breath sounds.

ANS: B

Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

5. A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client’s arteriovenous shunt?

a.            Palpable distal pulses

b.            A pink, warm extremity

c.             The presence of a bruit

d.            Shunt pressure higher than 25 mm Hg

ANS: C

Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Therapeutic Procedures) MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure?

a.            Tachycardia

b.            Hypovolemia

c.             Hyperkalemia

d.            Hemorrhage

ANS: B

The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

7. The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching?

a.            “I need to see a lawyer because I do not expect to recover from this disease.”

b.            “I will have to take things slowly for several months after I leave the hospital.”

c.             “I expect to be able to return to work in construction soon after I get discharged.”

d.            “I wonder if my family will be able to manage my care now that I am paralyzed.”

ANS: B

Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Stress Management)

MSC: Integrated Process: Teaching/Learning

8. The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?

a.            Inability to perform the six cardinal positions of gaze

b.            Lateralization to the affected side during the Weber test

c.             Absent deep tendon reflexes

d.            Impaired stereognosis

ANS: A

The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 991

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)