NUR 2212 Neuro Evolve Questions 2
A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré
syndrome, and amyotrophic lateral
... [Show More] sclerosis (ALS). Which information should the
nurse consider when planning care for this group of clients?
1 Progressive deterioration until death
2 Deficiencies of essential neurotransmitters
Correct3 Increased risk for respiratory complications
4 Involuntary twitching of small muscle groups
All three share increased risk for respiratory complications. As a result of muscle weakness, the vital
capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also
lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with
treatment, and clients with GuillainBarré syndrome may experience a complete recovery. None of these
diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a
decreased number of receptor sites. Twitching is not expected with myasthenia gravis or GuillainBarré
syndrome.
19.
The family member of a client with newly diagnosed Guillain-Barré syndrome comes
out to the nurse's station and informs the nurse that the client is having difficulty
breathing. What is the first action the nurse should do?
1 Notify the healthcare provider.
Correct2 Go with the family member to assess the client.
3 Send the nursing assistive personnel to take vital signs.
4 Assure the family member this is a normal response for this disease.
The initial response for the nurse is to assess the client to ensure a patent airway. GuillainBarré
syndrome will exhibit ascending paralysis and can impede respiratory function. The healthcare provider
will be notified after the nurse has assessed the client. The nurse needs to personally assess the client
since this is a change in condition; the nurse should not send the nursing assistive personnel to assess
the client. This is not a normal response to this disease, so it is not correct to assure the family member of
this.
29.
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré
syndrome. Which assessment is priority?
1 Urinary output
2 Sensation to touch
3 Neurologic status
Correct4 Respiratory exchange
The respiratory center in the medulla oblongata can be affected with acute GuillainBarré syndrome
because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure.
Although urinary output, sensation to touch, and neurologic status are important, none of them are the
priority.
30.
What nursing intervention is anticipated for a client with Guillain-Barré syndrome?
1 Providing a straw to stimulate the facial muscles
Correct2 Maintaining ventilator settings to support respiration
3 Encouraging aerobic exercises to avoid muscle atrophy
4 Administering antibiotic medication to prevent pneumonia
GuillainBarré syndrome is a progressive paralysis beginning with the lower extremities and moving
upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a
straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated,
depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis,
the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically;
antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.
A client with Guillain-Barré syndrome has been hospitalized for three days. Which
assessment finding would the nurse expect and need to monitor frequently in this
client?
1 Localized seizures
2 Skin desquamation
3 Hyperactive reflexes
Correct4 Ascending weakness
The classic feature of GuillainBarré syndrome is ascending weakness, beginning in the lower
extremities and progressing to the trunk, upper extremities, and face; more frequent assessment,
especially of respiratory status, is needed. Localized seizures are not a characteristic of GuillainBarré
syndrome. Skin desquamation is not a characteristic of GuillainBarré syndrome. Deep tendon reflexes
are absent with GuillainBarré syndrome.
A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré
syndrome. Which question by the nurse will best elicit information that supports
this diagnosis?
Correct1 "Have you experienced an infection recently?"
2 "Is there a history of this disorder in your family?"
3 "Did you receive a head injury during the past year?"
4 "What medications have you taken in the last several months?"
Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases
such as viral hepatitis, the EpsteinBarr virus, and infectious mononucleosis. There is no known familial
tendency that exists in the development of GuillainBarré syndrome. This syndrome is unrelated to head
trauma. Drug therapy is not implicated as a contributing factor in GuillainBarré syndrome.
33.
During the neurologic assessment of a client with a tentative diagnosis of GuillainBarré syndrome, what does the nurse expect the client to manifest?
1 Diminished visual acuity
Correct2 Increased muscular weakness
3 Pronounced muscular atrophy
4 Impairment in cognitive reasoning
Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves
become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than
sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination
occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later
if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is
unaffected [Show Less]