MSN Exam for Guillain-Barré Syndrome

EXPLANATION

 

✔Correct answer:

Huntington's disease. Huntington's disease is a genetic disorder characterized by the progressive degeneration of the basal ganglia and cerebral cortex. This condition leads to a decline in motor control, cognitive function, and mental health. Symptoms typically include chorea (involuntary, jerky movements), mental deterioration, and psychiatric problems such as depression and anxiety. The chronic progression and combination of motor, cognitive, and psychiatric symptoms are hallmark signs of Huntington's disease.

Think of Huntington's disease as a computer system where both the central processing unit (basal ganglia) and the software (cerebral cortex) are slowly deteriorating, leading to glitches in both the hardware (motor skills) and software (cognitive and mental functions).

Nurses should focus on managing symptoms, providing support for cognitive and mental health, and assisting with daily living activities for patients with Huntington's disease.

• Monitor and manage motor symptoms to prevent injuries and enhance mobility.
• Provide cognitive and mental health support, including counseling and medication management as prescribed.
• Educate the patient and family about the progression of the disease and available supportive therapies.
• Encourage participation in support groups for emotional and social support.
• Coordinate care with a multidisciplinary team, including neurologists, physical therapists, occupational therapists, and mental health professionals.

 

✘Incorrect answer options:

Multiple sclerosis. Multiple sclerosis is a chronic autoimmune disease that affects the central nervous system, leading to demyelination and a range of neurological symptoms. It does not primarily involve the degeneration of the basal ganglia and cerebral cortex, and it typically presents with relapsing-remitting or progressive neurological deficits rather than chorea and significant mental deterioration.

Myasthenia gravis. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. It does not cause degeneration of the basal ganglia and cerebral cortex, and it primarily involves muscle weakness rather than cognitive decline or mental deterioration.

Guillain-Barre syndrome. Guillain-Barre syndrome is an acute autoimmune condition that affects the peripheral nervous system, leading to ascending paralysis and potentially respiratory failure. It does not involve chronic progression or degeneration of the basal ganglia and cerebral cortex.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

The client's breathing is even and unlabored.  In patients with Guillain-Barré Syndrome (GBS), respiratory function is a critical area to monitor. GBS can lead to ascending paralysis that affects the respiratory muscles, potentially resulting in respiratory failure. Ensuring that the client's breathing remains even and unlabored is the most significant finding as it indicates that the respiratory muscles are functioning properly and the patient is not experiencing respiratory distress.

Think of the body's respiratory system like a car engine. If the engine (respiratory muscles) is running smoothly, the car (body) can function properly. However, if the engine starts to fail, the car won't run correctly, which is critical to address immediately.

Nurses should prioritize the assessment of respiratory function in patients with GBS and take prompt action if any signs of respiratory compromise are observed.

• Regularly assess respiratory rate, effort, and oxygen saturation levels to detect early signs of respiratory muscle weakness.
• Monitor for signs of respiratory distress, such as increased work of breathing, use of accessory muscles, or changes in voice or speech patterns.
• Be prepared to initiate respiratory support, such as supplemental oxygen or mechanical ventilation, if the patient shows signs of respiratory compromise.
• Collaborate with the healthcare team to ensure a comprehensive plan is in place for monitoring and managing the patient's respiratory status.
• Educate the patient and family about the importance of reporting any new or worsening respiratory symptoms immediately.

 

✘Incorrect answer options:

The client's skin is warm to the touch. While skin temperature can indicate perfusion and circulation status, it is not as critical as monitoring respiratory function in a patient with GBS.

The client's urine output is 50 ml per hour. This urine output is within normal limits and does not indicate a significant issue related to GBS. Monitoring urine output is important, but it is not the primary concern in this context.

The client's abdomen is soft and not distended. This finding is normal and does not relate directly to the primary concerns associated with GBS, which focus more on neuromuscular and respiratory function.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

A patient with chronic migraines needing pain management and routine neurological observations.  Nurse Thompson, with only one week of experience on the neurologic unit, should be assigned a patient whose care is less complex and within her current level of experience. A patient with chronic migraines needing pain management and routine neurological observations is appropriate for her. This assignment allows her to become familiar with neurological assessments and pain management without the complexity and intensity of care required by the other patients.

Think of Nurse Thompson's experience level like a beginner driver learning to navigate city streets. Assigning her to a patient with chronic migraines is like giving her a straightforward route to drive, while the other patients would be like asking her to navigate through complex and high-traffic routes.

 

✘Incorrect answer options:

A patient with a recent traumatic brain injury requiring frequent neurological assessments and complex care. This patient requires a high level of expertise in neurological assessments and complex care, which may be beyond Nurse Thompson's current level of experience.

A patient with advanced amyotrophic lateral sclerosis (ALS) requiring ventilator support and intensive nursing care. This patient requires specialized knowledge and skills in managing ventilator support and intensive care, which may be too complex for Nurse Thompson at this stage.

A patient who has just undergone neurosurgery and requires detailed post-operative care and monitoring. Post-operative neurosurgical patients require detailed monitoring and care to manage potential complications, which may be beyond Nurse Thompson's current capabilities given her limited experience.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Offering information, providing positive feedback, and fostering relaxation techniques. Providing information helps the client understand their condition and the treatment plan, reducing anxiety and fostering a sense of control. Positive feedback can encourage the client and promote a positive outlook. Relaxation techniques, such as deep breathing exercises and guided imagery, can help the client manage stress and improve their overall well-being. This holistic approach supports the client's emotional and psychological needs, which is crucial for coping with the illness.

Think of the support strategies like a toolkit for a traveler on a challenging journey. Providing a map (information), encouragement (positive feedback), and rest stops (relaxation techniques) can help the traveler navigate and endure the journey more effectively.

Nurses should focus on holistic care that addresses both the physical and emotional needs of patients with serious conditions like Guillain-Barré syndrome.

• Regularly update the client on their condition and treatment plan to reduce uncertainty and anxiety.
• Provide positive reinforcement and acknowledge the client's efforts and progress, no matter how small.
• Incorporate relaxation techniques such as deep breathing exercises, meditation, or guided imagery into the care plan to help the client manage stress and anxiety.
• Ensure open communication and involve the client in care decisions as much as possible, respecting their autonomy and preferences.
• Encourage family involvement and support, allowing visitors to provide emotional support to the client.

 

✘Incorrect answer options:

Offering positive feedback and promoting active range of motion exercises. While positive feedback is important, active range of motion exercises may not be appropriate for a client with ascending paralysis and on mechanical ventilation. Passive range of motion exercises might be more suitable.

Administering sedatives intravenously, minimizing distractions, and restricting visitors. This approach may not address the client's emotional and psychological needs and can increase feelings of isolation and anxiety. Sedatives should be used judiciously and not as the primary means of coping support.

Granting the client complete autonomy over care decisions and limiting visitor access. While it is important to involve the client in care decisions, complete autonomy may be overwhelming, and limiting visitor access can reduce essential emotional support. A balanced approach that includes family involvement is more beneficial.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Experiencing a respiratory or gastrointestinal infection in the previous month. Guillain-Barré syndrome (GBS) is often preceded by an infection, particularly respiratory or gastrointestinal infections. These infections can trigger an abnormal immune response, where the body's immune system mistakenly attacks the peripheral nerves, leading to the symptoms of GBS. Therefore, asking the client about any recent respiratory or gastrointestinal infections can help identify potential triggers for the condition.

Think of the immune system like a security system in a building. If it mistakenly identifies friendly staff (nerves) as intruders after a false alarm (infection), it may start attacking them, leading to issues (GBS symptoms).

Nurses should obtain a thorough history from patients with GBS to identify potential triggers and provide appropriate care and education.

• Ask detailed questions about recent infections, particularly respiratory and gastrointestinal infections, to identify potential triggers for GBS.
• Document any history of recent infections and communicate this information to the healthcare team for further evaluation and management.
• Educate the patient and family about the typical course of GBS and the importance of early identification and treatment of infections to prevent exacerbations.
• Monitor the patient for any signs of infection and report any findings promptly to the healthcare provider.

 

✘Incorrect answer options:

Any back injury or trauma to the spinal cord. While back injuries or spinal cord trauma can cause neurological symptoms, they are not known triggers for Guillain-Barré syndrome.

Seizures or any form of trauma to the brain. Seizures and brain trauma are not typically associated with the development of Guillain-Barré syndrome. GBS is more commonly triggered by infections affecting the peripheral nervous system.

Contracting meningitis in the past five years. Although meningitis can affect the nervous system, it is not a common trigger for Guillain-Barré syndrome. Recent respiratory or gastrointestinal infections are more relevant triggers for GBS.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

"It might be hard to believe, but the paralysis from this condition is often temporary." Guillain-Barré syndrome (GBS) is an acute condition that typically involves rapid-onset muscle weakness and paralysis. However, unlike many other causes of paralysis, the paralysis associated with GBS is often temporary. Most patients with GBS recover fully or partially over time, with recovery often beginning within weeks to months after the initial onset of symptoms. Nurse Williams should reassure the patient that while the current paralysis is distressing, there is a strong possibility of improvement and eventual recovery.

Think of Guillain-Barré syndrome as a temporary shutdown of a computer due to a power surge. While the shutdown is alarming and inconvenient, the computer (body) can often be restarted (recovery process) and return to normal function after some time.

Nurses should provide emotional support and clear, accurate information to patients with Guillain-Barré syndrome to help them understand their condition and the expected course of recovery.

• Reassure the patient that most cases of Guillain-Barré syndrome result in significant recovery, although the process may take time.
• Provide information on the typical progression and timeline of recovery from GBS.
• Encourage the patient to stay positive and participate in rehabilitation and physical therapy as recommended.
• Offer emotional support and address any concerns or fears the patient may have regarding their condition and recovery.
• Monitor the patient's respiratory function closely and ensure proper management while on mechanical ventilation.

 

✘Incorrect answer options:

"The recovery process usually begins with your legs, then progresses to your arms." While this statement might describe the general recovery pattern for some patients, it does not directly address the patient's concern about the temporality of the paralysis. It is more important to reassure the patient that the paralysis is often temporary.

"You need to come to terms with the permanence of the paralysis, but you won't lose any sensation." This statement is incorrect because it falsely implies that the paralysis is permanent. Guillain-Barré syndrome typically involves temporary paralysis with a good prognosis for recovery.

"Understanding and accepting the permanence of your paralysis can be incredibly difficult." This statement is inappropriate as it suggests that the paralysis is permanent, which is not accurate for most cases of Guillain-Barré syndrome. The condition is generally temporary, and many patients recover fully or partially over time.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

Consider making an exception to the visiting hours policy, acknowledging the prolonged recovery period of the client and the importance of family support. Guillain-Barré syndrome is a serious condition that can lead to prolonged hospitalization and significant emotional and physical challenges for both the patient and their family. Family support plays a crucial role in the patient's recovery and well-being, especially when communication is limited to eye blinks due to quadriplegia. Allowing the family to visit outside of standard visiting hours can provide much-needed emotional support to the patient and help the family stay involved in the care process. Flexibility in visiting hours can be beneficial in fostering a supportive environment for recovery.

Imagine a plant that needs sunlight (family support) to thrive. If the sunlight is only available at certain times, the plant may not get enough light. Allowing sunlight at different times ensures the plant gets the necessary support to grow strong.

Nurses should consider the individual needs of patients and their families, balancing hospital policies with compassionate care to support the best possible outcomes.

• Discuss the family's request with the healthcare team and administration to explore the possibility of making an exception to the visiting hours policy.
• Explain to the family the importance of their presence and how it can positively impact the patient's recovery.
• Coordinate with the family to establish a visiting schedule that accommodates their availability while minimizing disruptions to the patient's rest and care routines.
• Monitor the patient's response to extended visiting hours and make adjustments as needed to ensure the patient's well-being.
• Communicate the decision and rationale to other staff members to maintain consistency and understanding of the exception.

 

✘Incorrect answer options:

Recommend that the family members visit the client in shifts during standard visiting hours, emphasizing the client's need for rest at night. While rest is important, this option does not address the family's unique circumstances and may limit the vital support the patient needs from their family.

Organize for a volunteer to accompany the client during the day, ensuring the client's social and communication needs are met. While this can provide additional support, it does not replace the emotional and psychological benefits of having the family present.

Explain the importance of maintaining consistency in the enforcement of visiting rules to avoid grievances from other clients' families. Consistency in rules is important, but individual patient and family needs should also be considered. Exceptions can be made based on the patient's condition and the family's situation to provide the best possible care.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.

EXPLANATION

 

✔Correct answer:

pH, 7.25; PaCO2 50 mm Hg .Respiratory acidosis occurs when the lungs cannot remove enough carbon dioxide (CO2) from the body, leading to an accumulation of CO2 in the blood. This results in a decrease in blood pH, making it more acidic. To confirm respiratory acidosis, Nurse Benson should look for a combination of low pH (indicating acidosis) and high PaCO2 (indicating hypercapnia).

ABG Values:

• pH: Normal range is 7.35 to 7.45. A pH lower than 7.35 indicates acidosis.
• PaCO2: Normal range is 35 to 45 mm Hg. A PaCO2 higher than 45 mm Hg indicates respiratory acidosis.

In this option, the pH is 7.25 (indicating acidosis), and the PaCO2 is 50 mm Hg (indicating elevated CO2 levels). This combination confirms respiratory acidosis.

Guillain-Barré syndrome can lead to muscle weakness, including the muscles that control breathing. When these muscles are weakened, the patient may not be able to breathe deeply or rapidly enough, resulting in reduced alveolar ventilation. This causes CO2 to accumulate in the blood, lowering the pH and leading to respiratory acidosis.

Think of the lungs as an air conditioning system that removes CO2 (waste gas) from the blood. If the air conditioner is not working well (muscle weakness from Guillain-Barré syndrome), CO2 builds up inside (blood), making the room hotter (more acidic pH).

Nurses must take specific steps to manage respiratory acidosis effectively.

• Monitor the client's respiratory status closely, including rate, depth, and effort of breathing.
• Administer oxygen as prescribed to improve oxygenation and reduce hypoxia.
• Encourage and assist with deep breathing exercises to enhance alveolar ventilation.
• Prepare for possible interventions such as noninvasive positive pressure ventilation (NPPV) or mechanical ventilation if necessary.
• Assess and manage potential underlying causes of reduced alveolar ventilation, such as muscle weakness or airway obstruction.
• Reassure and educate the client about their condition and the importance of following respiratory therapy protocols.

 

✘Incorrect answer options:

pH, 5.0; PaCO2 30 mm Hg This option is incorrect because a pH of 5.0 is not compatible with life. Additionally, a PaCO2 of 30 mm Hg indicates low CO2 levels, which would suggest respiratory alkalosis, not acidosis.

pH, 7.40; PaCO2 35 mm Hg This option is incorrect because both the pH and PaCO2 values are within the normal range. A normal pH of 7.40 does not indicate acidosis, and a PaCO2 of 35 mm Hg is normal.

pH, 7.35; PaCO2 40 mm Hg This option is incorrect because while the pH of 7.35 is on the lower end of the normal range, it does not indicate acidosis. Additionally, a PaCO2 of 40 mm Hg is within the normal range, not suggesting respiratory acidosis.

 

References

• Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.
• Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.