Chapter 46: Care of Patients with Problems of the Peripheral Nervous System

Chapter 46: Care of Patients with Problems of the Peripheral Nervous System

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

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)