Quizlet the nurse would assess for trigeminal neuralgia in patients with which conditions

An environmental factor or virus triggers the activation of T cells in genetically susceptible individuals.

The activated T cells in the systemic circulation migrate to the central nervous system (CNS), disrupting the blood-brain barrier.

The antigen-antibody reaction within the CNS activates the inflammatory response, causing demyelination of axons.

The ongoing inflammation affects the nearby oligodendrocytes, and the myelin loses the ability to regenerate.

The underlying axon gets damaged, disrupting transmission of nerve impulses and loss of nerve function

The inflammation subsides, and the glial scar tissue replaces the damaged tissue, forming hard, sclerotic plaques.

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Terms in this set (95)

When providing care to a patient on a neurologic unit, the nurse notes that the patient is experiencing areflexia. Which diagnosis does the nurse anticipate for this patient?

Guillain-Barré syndrome

The nurse recalls that the steps involved in the pathophysiology of Guillain-Barre syndrome (GBS) and recovery from GBS occur in what order?

-The nerve undergoes slow remyelination

-The transmission of nerve impulses is slowed or stopped.

-The muscle innervated by the damaged nerve undergoes denervation and atrophy

-The myelin layer of the affected nerves is lost

-The neurologic function returns in a proximal-to-distal pattern

The nurse is preparing educational materials about the differences between Bell's palsy and trigeminal neuralgia. What information should the nurse include about Bell's palsy?

It affects the seventh cranial nerve, whereas trigeminal neuralgia affects the fifth.

The nurse is presenting information to a group of nursing students about the incidence of trigeminal neuralgia. What is appropriate for the nurse to include?

It usually affects only one side of the body

A patient has been diagnosed with trigeminal neuralgia. For which etiologic factors should the nurse assess the patient? Select all that apply.

-Brainstem infarct

-Herpes virus infection

-Infection of the teeth and jaw

A patient diagnosed with Guillain-Barré syndrome has a weak gag reflex. For which complication associated with a weak gag reflex should the nurse intervene?

Aspiration of food into the airways

A nurse is preparing a nursing care plan for a patient with trigeminal neuralgia. What information should the nurse elicit during the patient's health history to aid in planning? Select all that apply.

-Food habits

-Self-medication to decrease pain

-Frequency of attacks and triggers

The nurse is providing teaching to a group of nursing students about the actions of the primary medications used to treat trigeminal neuralgia. What is appropriate for the nurse to include in the education? Select all that apply.

-Lamotrigine blocks the nerve firing

-Nortriptyline can be used to treat constant burning

A patient having trigeminal neuralgia has been prescribed antiseizure drugs. The patient asks the nurse about how the drug would prevent painful episodes. What explanation should the nurse give in order to explain the mechanism of action of the drug?

It attenuates the transmission of nerve impulses from the trigeminal nerve

The nurse recalls that which surgical therapy for trigeminal neuralgia is a peripheral procedure?

Glycerol rhizotomy

The oral intake of a patient with trigeminal neuralgia is sharply reduced, and the patient's nutritional status is compromised. What is the priority nursing intervention?

Providing food through a nasogastric tube

A nurse is explaining to a patient with Bell's palsy the preventive measures for complications related to the eye. What instructions should the nurse give the patient? Select all that apply.

-Wear dark glasses

-Tape eyelids at night

-Instill artificial tears frequently

Which cranial nerve does the nurse know is associated with tic douloureux?

V

A patient develops Bell's palsy weeks after being diagnosed with a middle ear infection. What explanation should the nurse give when asked about the cause of the condition?

A virus causes inflammation, which leads to paralysis of the facial nerve

A patient presents with initial manifestations of tetanus. The nurse expects what assessment finding?

Stiffness in the jaw

Which of the following assessment findings demonstrates effective use of carbamazepine in the patient with trigeminal neuralgia?

Less frequent and severe facial pain

The nurse is providing care for a patient who has been diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority ?

Respiratory assessment

The nurse is preparing educational materials about the differences between the facial characteristics of Bell's palsy and those of trigeminal neuralgia. What characteristics of Bell's palsy should the nurse include? Select all that apply.

-Unable to whistle

-Flat nasolabial fold

A patient has been diagnosed with botulism. The nurse is explaining to the patient and the caregivers about the pathology involved in the disease. What points should the nurse emphasize while explaining it? Select all that apply.

-The spores of the organism are difficult to destroy

-This neurotoxin inhibits nerve impulses from reaching the muscle

-The neurotoxin produced by the bacteria is absorbed in the gastrointestinal (GI) tract.

A patient asks the nurse about the differences between trigeminal neuralgia and Bell's palsy. What symptoms of trigeminal neuralgia should the nurse include in the teaching? Select all that apply.

-Tearing of the eye

-Pain on the side of the nose

What body system is the major focus for nursing care of the patient with Guillain-Barré syndrome?

Respiratory

The nurse is caring for a patient with trigeminal neuralgia. What conservative therapies are appropriate to be included on the patient's plan for treatment? Select all that apply.

-Acupuncture

-Vitamin therapy

The nurse is providing care to a patient with trigeminal neuralgia. Which first-line drug prescribed to this patient does the nurse prepare to administer?

Carbamazepine

A patient has had two episodes of trigeminal neuralgia and has lately been exhibiting strange mannerisms. The nurse identifies them to be coping strategies to avoid another episode. What observed mannerisms would have led the nurse to conclude this? Select all that apply.

-Patient has stopped eating

-Patient covers the face with a cloth

-Patient avoids interacting with people

The patient with trigeminal neuralgia asks the nurse about the incidence and how this condition is diagnosed. Which responses by the nurse are most accurate? Select all that apply.

-"90% of the cases occur in people over age 50."

-"It is one of the most commonly diagnosed neuralgic conditions."

-"The cause and physical aspects of trigeminal neuralgia are not well known."

-"Every year, about 12 in 100,000 Americans are diagnosed with this condition."

The nurse is preparing educational materials about Guillain-Barre syndrome (GBS) and Bell's palsy. How is GBS different than Bell's palsy?

GBS is a potentially fatal disorder

The nurse provides preoperative information to a patient with trigeminal neuralgia. The nurse explains that the surgery involves destruction of the sensory fibers of the trigeminal nerve using low-voltage current. What surgery is planned for the patient?

Percutaneous radiofrequency rhizotomy

The respiratory status of a patient with Guillain-Barré syndrome is deteriorating. What nursing interventions should be performed for this patient? Select all that apply.

-Check for fever, and send for sputum culture

-Keep necessary equipment ready for mechanical ventilation and tracheostomy

-Regular pulmonary functions tests and arterial blood gas (ABG) should be taken

The nurse is caring for a patient with trigeminal neuralgia and identifies that the patient is at risk for what? Select all that apply.

-Multiple sclerosis

-Herpesvirus infection

A patient presents with an open wound. The nurse reviews the patient's history and determines that a tetanus booster is not necessary. This determination was made because the patient was immunized against tetanus within the past how many years? Record the answer as a whole number. _______ years

5 years

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. What instructions should the nurse give this patient? Select all that apply

-Avoid eating hot food or beverages

-Protect the face from extreme temperatures

-Check oral cavity after eating food for any residual food particles

The nurse is providing care to a patient with trismus. Which associated condition does the nurse suspect?

Tetanus

A patient, injured at work with an open cut, asks the occupational health nurse whether a "tetanus shot" is needed. The nurse should base the response on which of the following facts?

When the patient last received a tetanus toxoid booster

While assessing a patient, the health care provider observes that the patient has trismus and suspects the patient has a tetanus infection. How would the nurse describe trismus and its relation to tetanus infection?

Trismus is stiffness of the jaw and is one of the first manifestations of tetanus

Which discharge instruction should the nurse provide to a patient with trigeminal neuralgia?

"Eat a diet that is high in protein."

The nurse teaches a community group about tetanus prevention and immunizations. The nurse should instruct the adults to receive a tetanus and diphtheria toxoid booster, then wait how many years until another is received? Record the answer using a whole number. __________ years

10

Which noninvasive surgical procedure is often performed in patients with trigeminal neuralgia?

Gamma knife radiosurgery

The nurse reviews a patient's medical record and notes tic douloureux. The nurse expects what assessment finding?

Recurrent episodes of stabbing pain along the distribution of the trigeminal nerve

The nurse that is caring for a patient with Bell's palsy should monitor for what complications? Select all that apply.

-Corneal abrasions

-Psychologic withdrawal

-Mucous membrane trauma

A patient with trigeminal neuralgia is scheduled for microvascular decompression of the trigeminal nerve. What is appropriate for the nurse to teach the patient about the procedure? Select all that apply.

-"It will be performed by making a small hole behind your ear."

-"It involves displacement of the blood vessels pressing on the nerve."

A patient is diagnosed with Bell palsy. Which cranial nerve does the nurse teach the patient is associated with the disorder?

VII

A patient with Guillain-Barré syndrome is admitted to the medical-surgical floor. What does the nurse understand regarding this disorder?

Patients also may have syndrome of inappropriate antidiuretic hormone (SIADH)

Which instruction should be given to a patient who is diagnosed with Bell's palsy?

Prevent corneal drying by instillation of ointment at night with an eye shield

The nurse differentiates between the clinical manifestations of Guillain-Barre syndrome (GBS) that are related to autonomic nervous system dysfunction and those that are related to cranial nerve involvement. What does the nurse identify as a clinical manifestation that is related to the autonomic nervous system?

Facial flushing

A patient has undergone a percutaneous radiofrequency rhizotomy procedure for trigeminal neuralgia and has facial numbness and trigeminal motor weakness on the affected side. What instructions should the nurse give this patient? Select all that apply.

-Avoid eating hot food or beverages.

-Protect the face from extreme temperatures

-Check oral cavity after eating food for any residual food particles

A patient's surgical therapy for trigeminal neuralgia resulted in an altered corneal reflex. The nurse provides education about long-term management of the reflex. Which statements made by the patient indicate the need for further teaching? Select all that apply.

-"I will go for an annual dental visit."

-"I will avoid ice cream and cold beverages."

The nurse recognizes that which medications are considered to be first-line drugs for treatment of trigeminal neuralgia? Select all that apply.

-Phenytoin

-Topiramate

-Clonazepam

-Carbamazepine

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate?

Conus medullaris syndrome

A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply.

-Bradycardia

-Hypotension

-Peripheral vasodilation

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?

Spinal shock syndrome

A patient has been admitted to the hospital with a spinal cord injury. Following the assessment, the health care provider concludes that the injury is above T12. What signs and symptoms related to the gastrointestinal system would indicate an injury above T12? Select all that apply.

-There is excess gastric distention, and the stomach is hard

-The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present

A patient with a spinal cord injury (SCI) at the level of the seventh cervical vertebra (C7) has experienced episodes of autonomic dysreflexia. What signs and symptoms occur with this condition? Select all that apply.

-Sudden onset of severe headache

-Sweating above the level of the SCI

-Flushed face and chest above the level of the SCI

A nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, what should the nurse instruct the patient to avoid?

Urine retention

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver about to assist the patient with bowel evacuation? Select all that apply.

-Eat 20 to 30 g of fiber per day

-Drink 1800 to 2800 mL of water or juice

A patient with facial paralysis comes to the walk-in clinic and is diagnosed with Bell's palsy. What does the nurse understanding about this disorder?

Can affect any age group

The arterial blood gas (ABG) report of a patient with a spinal cord injury reveals that the patient is in respiratory distress. Which nursing interventions, if prescribed, are appropriate for this patient? Select all that apply.

-Administer oxygen

-Perform tracheal suctioning

-Use assisted coughing techniques

A computed tomography (CT) scan has to be completed for a patient with spinal cord injury. The nurse has to explain the uses of this procedure to the caregivers in order to obtain their consent. What should the nurse tell the caregivers? Select all that apply.

-It helps to find the exact location of injury

-It helps to find the degree of spinal canal compromise

A patient with paraplegia has been hospitalized for a week and is not eating anything. What could be the possible causes of patient's anorexia? Select all that apply.

-Depression

-Hurried feeding by the nurse

-Boredom due to institutional food

-Continuous bed rest and weakness

A patient with spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient states to the nurse, "I can't believe this is happening to me." Which nursing actions are appropriate for this patient? Select all that apply.

-Encourage the patient to set daily goals

-Encourage the patient to participate in care

-Teach the patient what to expect during the rehabilitation period

A patient with a cervical spinal cord injury has just been hospitalized. Which nursing interventions for maintaining nutritional balance, if prescribed, are appropriate for this patient? Select all that apply.

-Insert a nasogastric tube

-Evaluate swallowing before starting oral feeding

-If oral feeding is not possible, enteral nutrition must be provided

A patient with a T1-level spinal cord injury is soon to be discharged from the hospital. The nurse has to plan the home care for neurogenic bowel management. What should the nurse include in the care plan? Select all that apply.

-Explain the use of stool softeners.

-Advise the patient to eat a high-fiber diet

-Teach the patient how to use suppositories for evacuation

-Teach the patient to perform digital stimulation of the rectum

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?

Headache and rising blood pressure

A patient with spinal cord injury has begun to get stress ulcers. What nursing interventions should be performed for this patient? Select all that apply.

-Check stools for blood

-Motivate the patient and provide a stress-free environment

-Administer proton pump inhibitors for prophylaxis as prescribed

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority ?

Ineffective airway clearance caused by high cervical spinal cord injury

A patient is suspected of having cervical cord injury following a motor vehicle accident. Which nursing interventions are appropriate for this patient to stabilize the cervical spine? Select all that apply.

-Ensure that the patient's body is correctly aligned

-Use a sternal-occipital-mandibular immobilizer brace

-Use a firm backboard to prevent any spinal movement

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia

Which is a priority nonoperative treatment following a spinal cord injury?

Stabilization

A patient with a T3-level spinal cord injury has been discharged from the hospital with an indwelling catheter for neurogenic bladder. The nurse is teaching the patient regarding the care for indwelling catheters. What instructions should the nurse give regarding home care for indwelling catheters? Select all that apply.

-Cleanse the catheter regularly

-Check for the presence of any folds or kinks in the catheter tube

-Check for signs of urinary tract infection (fever, change in odor or color of urine).

A person who has survived a motor vehicle accident has been diagnosed as having a thoracic level spinal cord injury. A week into hospitalization, the patient is put on mechanical ventilation. The nurse has to explain to the caregivers the reason for mechanical ventilation. What could be the reason for the need for mechanical ventilation in this patient? Select all that apply.

-There is fluid overload in the lungs

-The muscle responsible for breathing is paralyzed

-There is accumulation of secretions in the lungs, which has caused collapse of the lungs

The nurse is caring for a patient with a spinal cord injury who demonstrates motor paralysis and a loss of pain and temperature sensation below the level of injury. What may be the causative factor of this condition?

Damage to the anterior spinal artery

A patient has been admitted to the hospital with a T3-level complete spinal cord injury. The nurse has to plan the home-based rehabilitation for this patient. When creating the care plan, the nurse considers the activities that the patient is able to do independently. What activities should the nurse consider to make maximum use of patient's abilities? Select all that apply.

-Independent self-care is possible

-Independent wheelchair mobility is possible

-Patient may be able to drive with hand controls

A nurse is assessing a patient with a T2-level spinal cord injury. The nurse notices that there is a kink in the catheter, the bladder is distended, and the blood pressure is 220/100 mm Hg. What nursing interventions would be appropriate for this patient if the nurse suspects autonomic dysreflexia? Select all that apply.

-Monitor blood pressure regularly

-Notify the primary health care provider

-Check for the presence of bowel impaction

-Remove the kink in the catheter and drain the bladder

A nurse is explaining the mechanism of bladder dysfunction after a spinal cord injury to a caregiver. Arrange the pathologic events involved in their proper order.

-Renal failure

-Overdistention of the bladder

-No sensation of bladder filling

-Loss of autonomic and reflex control of the bladder and sphincter

An older adult person has fallen from a step stool and has a lower sacral fracture. The investigation reports also show that there is injury to the conus medullaris. What are the symptoms that the nurse should expect while assessing the patient? Select all that apply.

-Bowel incontinence

-Urinary incontinence

-Hypotonicity of the lower limbs

After learning about rehabilitation for a spinal cord tumor, which statement shows that the patient understands what rehabilitation is and can do for him or her?

"With rehabilitation, I will be able to function at my highest level of wellness."

A patient with paraplegia has sudden violent movements of the lower limbs. What should the nurse tell the patient and the caregivers about these violent spasms? Select all that apply.

-These spasms can occur as a result of a variety of stimuli

-Such reflexes could be positively used for bowel and bladder retraining

-This occurs due to a break in the link between the upper and lower motor neuron interaction

A patient has been admitted with a C5-level spinal cord injury and has marked hypotension. What pharmacologic therapies would the nurse expect to be prescribed for this patient? Select all that apply.

-Anticoagulants

-Intravenous fluids

The nurse is providing care to a patient who is paralyzed from the waist down. Which spinal vertebra injury would have caused this manifestation?

Lumbar vertebra 1

What type of blunt trauma can lead to a spinal cord injury?

Diving accident

Which interventions should be included in the teaching plan for the patient with paraplegia who is discharged from a rehabilitation facility? Select all that apply.

-Use pressure-relief devices while sitting

-Change position at least every two hours.

-Inspect all skin areas on a daily basis using a mirror as necessary

A patient with a history of prostate cancer is admitted to the hospital with severe back pain interfering with activity. A computerized tomography (CT) scan shows a metastatic tumor in the spine. Intravenous dexamethasone is prescribed. What is the desired effect of the medication?

Decrease tumor-related edema

The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation?

Spinal cord injury

A person is injured in a motor vehicle accident and is brought into the emergency department. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Applying a rigid cervical collar and using a backboard to transport the patient.

What health promotion activity will have the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older?

Fall prevention strategies

While assessing a patient's level of spinal injury, the nurse observes that the patient has sensation and movement in the neck and the region above, and can breathe without a ventilator. What is the potential for rehabilitation that the nurse can expect?

Ability to drive an electric wheelchair

A nurse is planning a bowel program for a patient with a T7 level spinal cord injury. What is the most suitable position for bowel evacuation for this patient?

Sitting position

Which diagnostic study is used to assess soft tissue injury and neurologic changes?

Magnetic resonance imaging (MRI)

A patient is admitted to the hospital after sustaining a C7 spinal cord injury. What is the most important nursing intervention during the acute stage of care?

Maintaining a patent airway

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. What does the nurse know about this injury?

Differences in drug metabolism are related to the level and completeness of the injury

The nurse is caring for a patient admitted to the hospital after a motor vehicle accident. The patient is unable to breathe independently and has been intubated and placed on a ventilator. On the basis of these data, which injury does the nurse suspect?

C1-3

The nurse is performing a musculoskeletal assessment on the older patient. Which is the most important factor considered by the nurse when performing the musculoskeletal assessment on the older patient?

Exercise practices

A patient with spinal cord injury has poor nutritional intake. What measures should the nurse take to improve the patient's nutrition? Select all that apply.

-Provide adequate time to eat

-Encourage intake of dietary fiber.

-Keep a calorie count of the food taken.

-Provide a pleasant eating environment

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia?

Urinary catheterization

A patient with spinal cord injury is suspected of having deep vein thrombosis. The health care provider advises the nurse to administer low-molecular-weight heparin. What should the nurse assess before initial administration of the drug? Select all that apply.

-Signs of any internal bleeding

-Any history of recent surgeries

What instructions should the nurse give to the patient and caregivers to prevent skin breakdown in the patient with spinal cord injury who can sit in the wheelchair? Select all that apply.

-Use special mattresses to reduce pressure

-Use wheelchair cushions to reduce pressure

-Use pillows to protect bony prominences when in bed

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What other neurological condition increases the risk for trigeminal neuralgia?

Which instruction would the nurse give the patient to assess the trigeminal nerve?

What comorbid conditions are linked to trigeminal neuralgia?

What are the symptoms of a patient with trigeminal neuralgia?