And again, nervous system

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition

Self-Assessment Questions

Chapter 44: Interventions for Clients with Problems of the Peripheral Nervous System


1.     Which statement regarding the pathophysiology of Guillain-Barré syndrome is true?

A.     The immune system destroys the myelin sheath.
B.     The axon cell body is attacked by white blood cells.
C.     Nerve impulses are not transmitted to the skeletal muscle.
D.     Chronic inflammatory demyelinating neuropathy is common.

Correct Answer: A


2.     The client has some clinical manifestations of Guillain-Barré syndrome. What question should you include in the collection of data for the history?

A.     “Do you can your own food?”
B.     “How long have you worn glasses or contact lenses?”
C.     “Have you traveled out of the country in the past month?”
D.     “Have you had any type of illness in the past two months?”

Correct Answer: D

3.     During an hourly assessment of a client with Guillain-Barré syndrome, you note the following changes. Which indicates a worsening of the client’s condition?

A.     Pulse rate decreases from 82 to 70
B.     Pulse pressure narrowed by 6 mm Hg
C.     Temperature elevation 0.5° C
D.     Increased confusion

Correct Answer: D

4.     The client with Guillain-Barré syndrome is receiving adrenocorticotropic hormone and intravenous immunoglobulin as drug therapy. Which of the following clinical manifestations indicates the therapy is effective?

A.     Positive Homan’s sign
B.     Mild fever and headache
C.     Increased handgrasp strength
D.     Increased blood immunoglobulin levels

Correct Answer: C


5.     Which of the following statements regarding myasthenia gravis is true? Paralysis or weakness results from:

A.     progressive deterioration of voluntary muscle fibers.
B.     an inability of motor nerves to generate an action potential.
C.     failure of nerve impulses to be transmitted to voluntary muscles.
D.     loss of upper motor neuron function while lower motor neuron function remains intact.

Correct Answer: C


6.     A client with myasthenia gravis is experiencing a cholinergic crisis. What clinical manifestations would you expect to be present in this client?

A.     Absence of swallow reflex
B.     Decreased urinary output
C.     Facial muscle twitching
D.     Increased pulse

Correct Answer: C


7.     Which of the following discharge instructions assists in preventing injury in the client with myasthenia gravis?

A.     Applying artificial tears
B.     Keeping a padded tongue blade at the bedside
C.     Using a picture or word board for communication
D.     Providing high-calorie, high-protein liquid snacks

Correct Answer: A


8.     The client has permanent polyneuropathy from exposure to neurotoxic chemotherapeutic agents. Which of the following lifestyle behaviors should the nurse teach this client to avoid?

A.     Wearing polyester clothing
B.     Drinking wine twice per week
C.     Exercising three times per week
D.     Smoking one pack of cigarettes per day

Correct Answer: D


9.     Which of the following interventions after surgical restoration of a transected nerve in the arm is recommended during the first postoperative week?

A.     Range-of-motion exercises to preserve function and prevent contractures
B.     Application of electrical stimulation to initiate Schwann cell production of myelin
C.     Casting in continuous joint flexion to avoid tension on the suture line
D.     Casting in continuous joint extension to avoid tension on the suture line

Correct Answer: C


10.     What is the priority nursing diagnosis for a client with trigeminal neuralgia?

A.     Risk for injury related to diminished sensation
B.     Pain related to paroxysmal nerve stimulation
C.     Risk for aspiration related to difficulty swallowing
D.     Body image disturbance related to weakened facial muscles

Correct Answer: B


11.     You are caring for a client with trigeminal neuralgia. Which medication should you be prepared to administer?

A.     Carbamazepine
B.     Midazolam
C.     Accupril
D.     Versed

Correct Answer: A


12.     The client with trigeminal neuralgia is scheduled for a Jannetta procedure. The client asks the purpose of this procedure. What is your best response? “This procedure will:

A.     prevent the spread of neuralgia to nearby nerves.”
B.     relieve pain without loss of facial sensation.”
C.     prevent involuntary facial movements.”
D.     prevent attacks of neuralgia.”

Correct Answer: B