Chapter 44: Care of Patients with Problems of the Peripheral Nervous System
1. The nurse is assessing a patient with a diagnosis of Guillain-Barré syndrome (GBS). Which signs and symptoms are
consistent with GBS? (Select all that apply.) a. Bilateral sluggish pupil response b. Sudden onset of weakness in the legs
c. Muscle atrophy of the legs d. Change in level of consciousness e. Decreased deep tendon reflexes f. Ataxia 2. During
shift report, the nurse hears that a patient with GBS has a decrease in vital capacity that is less than two-thirds of
normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is
coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient? a. Frequent oral
suctioning
b. Rigorous chest physiotherapy c. Elective intubation d. Elective tracheostomy 3. A patient with GBS is identified as
having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this
patient’s nutritional status? (Select all that apply.) a. Checking the patient’s skin turgor and urinary output b. Giving the
prescribed enteral feedings via feeding tube c. Weighing the patient three times a week d. Reviewing the patient’s
potassium and sodium levels e. Monitoring weekly serum prealbumin level 4. A patient with GBS has been intubated for
respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the
nurse closely monitor the patient for? a. Thick secretions b. Atrial fibrillation c. Cyanosis d. Bradycardia 5. A patient is
admitted for a probable diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which tests does the
nurse anticipate will be ordered for this patient? (Select all that apply.) a. Electroencephalography (EEG) b. Cerebral
blood flow (CBF) c. Electrophysiologic studies (EPS) d. Electrocardiogram (ECG) e. Electromyography (EMG) 6. The nurse
is reviewing the cerebral spinal fluid (CSF) results for a patient with probable GBS. Which abnormal finding is common in
GBS? a. Increase in CSF protein level b. Increase in CSF glucose level c. Cloudy appearance of CSF fluid d. Elevation of
lymphocyte count in CSF 7. An ambulatory patient has sought treatment for symptoms of GBS. IV immunoglobulin
therapy has been prescribed. Which precaution does the nurse expect with this therapy? a. It is given concurrently with
plasmapheresis. b. A shunt must be placed prior to beginning the therapy. c. IV immunoglobulin is given slowly when
started. d. Three or four treatments are given 1 to 2 days apart.
8. The patient with GBS is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? (Select
all that apply.) a. Elevate the head of the bed at least 45 degrees. b. Have patient assessed for dysphagia before
administering oral fluids or medications. c. Teach the patient coughing and deepbreathing exercises. d. Have suctioning
equipment available at the bedside. e. Turn the patient from side to side at least every 2 hours. 9. Which interventions
are appropriate for pain management in an older adult with GBS? (Select all that apply.) a. IV opiates b. Gabapentin
(Neurontin) c. Tricyclic antidepressants d. Massage e. Music therapy 10. A patient with GBS is receiving IV
immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. Headache b.
Itching
c. Anaphylaxis d. Fever 11. The nurse is monitoring a patient with GBS undergoing plasmapheresis. The patient reports
dizziness and has a heart rate that has dropped to 48 beats per minute. The nurse notifies the primary care provider.
Which order does the nurse anticipate? a. Atropine IV push b. Epinephrine IV push c. Continue to monitor the patient d.
Defibrillate the patient 12. A patient has been newly diagnosed with GBS. The nurse is teaching the patient and family
about the condition. Which statement by the family indicates a need for additional teaching? a. “He could recover in 4
to 6 months.” b. “He’ll never be able to walk again.” c. “He will receive medication for pain.” d. “It usually starts with the
legs and moves upward.” 13. Which strategies should be incorporated in the plan of care to provide emotional support
for a patient with GBS who has ascending paralysis? (Select all that apply.) a. Limit information provided to the patient
and family. b. Encourage the patient to verbalize feelings. c. Teach the patient and family about the condition. d. Explain
all procedures and tests. e. Allow regularly scheduled rest periods. f. Assess previous coping skills. 14. What is the
priority expected outcome in a patient with GBS? a. Maintain airway patency and gas exchange. b. Promote
communication. c. Manage pain. d. Prevent complications of immobility. 15. The nurse is reviewing the admission and
history notes for a patient admitted for GBS. Which medical condition is most likely to be present before the onset of
GBS? a. Diabetes mellitus b. Recent bacterial infection c. Peripheral vascular disease d. Addison’s disease 16. The patient
with GBS describes a chronological progression of motor weakness that started in the legs and then spread to the arms
and the upper body. Which type of GBS do these symptoms indicate? a. Ascending b. Pure motor c. Descending d.
Miller-Fisher variant 17. The patient with GBS is in the plateau period. Which intervention is best for the nurse to
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, delegate to the unlicensed assistive personnel (UAP)? a. Perform passive range of motion every 2 to 4 hours. b. Turn the
patient every 2
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1. The nurse is assessing a patient with a diagnosis of Guillain-Barré syndrome (GBS). Which signs and symptoms are
consistent with GBS? (Select all that apply.) a. Bilateral sluggish pupil response b. Sudden onset of weakness in the legs
c. Muscle atrophy of the legs d. Change in level of consciousness e. Decreased deep tendon reflexes f. Ataxia 2. During
shift report, the nurse hears that a patient with GBS has a decrease in vital capacity that is less than two-thirds of
normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is
coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient? a. Frequent oral
suctioning
b. Rigorous chest physiotherapy c. Elective intubation d. Elective tracheostomy 3. A patient with GBS is identified as
having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this
patient’s nutritional status? (Select all that apply.) a. Checking the patient’s skin turgor and urinary output b. Giving the
prescribed enteral feedings via feeding tube c. Weighing the patient three times a week d. Reviewing the patient’s
potassium and sodium levels e. Monitoring weekly serum prealbumin level 4. A patient with GBS has been intubated for
respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the
nurse closely monitor the patient for? a. Thick secretions b. Atrial fibrillation c. Cyanosis d. Bradycardia 5. A patient is
admitted for a probable diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which tests does the
nurse anticipate will be ordered for this patient? (Select all that apply.) a. Electroencephalography (EEG) b. Cerebral
blood flow (CBF) c. Electrophysiologic studies (EPS) d. Electrocardiogram (ECG) e. Electromyography (EMG) 6. The nurse
is reviewing the cerebral spinal fluid (CSF) results for a patient with probable GBS. Which abnormal finding is common in
GBS? a. Increase in CSF protein level b. Increase in CSF glucose level c. Cloudy appearance of CSF fluid d. Elevation of
lymphocyte count in CSF 7. An ambulatory patient has sought treatment for symptoms of GBS. IV immunoglobulin
therapy has been prescribed. Which precaution does the nurse expect with this therapy? a. It is given concurrently with
plasmapheresis. b. A shunt must be placed prior to beginning the therapy. c. IV immunoglobulin is given slowly when
started. d. Three or four treatments are given 1 to 2 days apart.
8. The patient with GBS is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? (Select
all that apply.) a. Elevate the head of the bed at least 45 degrees. b. Have patient assessed for dysphagia before
administering oral fluids or medications. c. Teach the patient coughing and deepbreathing exercises. d. Have suctioning
equipment available at the bedside. e. Turn the patient from side to side at least every 2 hours. 9. Which interventions
are appropriate for pain management in an older adult with GBS? (Select all that apply.) a. IV opiates b. Gabapentin
(Neurontin) c. Tricyclic antidepressants d. Massage e. Music therapy 10. A patient with GBS is receiving IV
immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. Headache b.
Itching
c. Anaphylaxis d. Fever 11. The nurse is monitoring a patient with GBS undergoing plasmapheresis. The patient reports
dizziness and has a heart rate that has dropped to 48 beats per minute. The nurse notifies the primary care provider.
Which order does the nurse anticipate? a. Atropine IV push b. Epinephrine IV push c. Continue to monitor the patient d.
Defibrillate the patient 12. A patient has been newly diagnosed with GBS. The nurse is teaching the patient and family
about the condition. Which statement by the family indicates a need for additional teaching? a. “He could recover in 4
to 6 months.” b. “He’ll never be able to walk again.” c. “He will receive medication for pain.” d. “It usually starts with the
legs and moves upward.” 13. Which strategies should be incorporated in the plan of care to provide emotional support
for a patient with GBS who has ascending paralysis? (Select all that apply.) a. Limit information provided to the patient
and family. b. Encourage the patient to verbalize feelings. c. Teach the patient and family about the condition. d. Explain
all procedures and tests. e. Allow regularly scheduled rest periods. f. Assess previous coping skills. 14. What is the
priority expected outcome in a patient with GBS? a. Maintain airway patency and gas exchange. b. Promote
communication. c. Manage pain. d. Prevent complications of immobility. 15. The nurse is reviewing the admission and
history notes for a patient admitted for GBS. Which medical condition is most likely to be present before the onset of
GBS? a. Diabetes mellitus b. Recent bacterial infection c. Peripheral vascular disease d. Addison’s disease 16. The patient
with GBS describes a chronological progression of motor weakness that started in the legs and then spread to the arms
and the upper body. Which type of GBS do these symptoms indicate? a. Ascending b. Pure motor c. Descending d.
Miller-Fisher variant 17. The patient with GBS is in the plateau period. Which intervention is best for the nurse to
This study source was downloaded by 100000852681095 from CourseHero.com on 11-08-2022 11:45:36 GMT -06:00
https://www.coursehero.com/file/35307531/Chapter-44-Care-of-Patients-with-Problems-of-the-Peripheral-Nervous-Systemdocx/
, delegate to the unlicensed assistive personnel (UAP)? a. Perform passive range of motion every 2 to 4 hours. b. Turn the
patient every 2
This study source was downloaded by 100000852681095 from CourseHero.com on 11-08-2022 11:45:36 GMT -06:00
https://www.coursehero.com/file/35307531/Chapter-44-Care-of-Patients-with-Problems-of-the-Peripheral-Nervous-Systemdocx/
