Chapter 44: Care of Patients with Problems of the Peripheral Nervous System

Chapter 44: Care of Patients with Problems of the Peripheral Nervous System

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?
   1. Bladder control
   2. Cognitive perception
   3. Respiratory system
   4. Sensory functions

ANS:   C

Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

DIF:     Applying/Application                         REF:    915                   KEY: Peripheral nervous system| respiratory assessment| nursing assessment MSC:    Integrated Process: Nursing Process: Assessment              NOT:                                                 Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what?
   1. Delayed afferent nerve impulses
   2. Paralysis of affected muscles
   3. Paresthesia in upper extremities
   4. Slowed nerve impulse transmission

ANS:   D

Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

DIF:     Remembering/Knowledge                 REF:    914                   KEY: Peripheral nervous system             MSC:                                                  Integrated Process: Teaching/Learning NOT:             Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
   1. Anxiety
   2. Low fluid volume
   3. Inadequate airway
   4. Potential for skin breakdown

ANS:   C

Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

DIF:            Analyzing/Analysis                            REF:    914                   KEY: Peripheral nervous system| respiratory system                                                  MSC: Integrated Process: Nursing Process: Analysis                      NOT:                                                 Client Needs Category: Safe and Effective Care Environment: Management of Care

4. The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
   1. Administering anxiolytics
   2. Having a ventilator nearby
   3. Obtaining atropine sulfate
   4. Sedating the client

ANS:           C

Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

DIF:     Applying/Application             REF:    919       KEY: Peripheral nervous system| medication adverse effects| diagnostic testing MSC:         Integrated Process: Nursing Process: Implementation            NOT:             Client Needs Category: Physiological Integrity: Reduction of Risk Potential