Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
1. 1. When assessing a patient with Correct Answer: D
newly diagnosed trigeminal neural- Rationale: The major clinical manifestation of trigem-
gia, the nurse will ask the patient inal neuralgia is severe facial pain that is triggered
about by cutaneous stimulation of the nerve. Ptosis, loss of
a. triggers that lead to facial pain. taste, and numbness are not characteristics of trigem-
b. visual problems caused by pto- inal neuralgia, although ptosis and numbness may oc-
sis. cur after therapy, and poor appetite may be associated
c. poor appetite caused by a loss of with pain stimulated by eating.
taste.
d. decreased sensation on the af- Cognitive Level: Application Text Reference: p. 1581
fected side. Nursing Process: Assessment NCLEX: Physiological In-
tegrity
2. 2. During assessment of the pa- Correct Answer: A
tient with a recurrence of symp- Rationale: Oral hygiene is frequently neglected be-
toms of trigeminal neuralgia, the cause of fear of triggering facial pain. Having the
nurse should patient clench the facial muscles will not be useful
a. examine the mouth and teeth because the sensory branches of the nerve are affect-
thoroughly. ed by trigeminal neuralgia. Light touch and palpation
b. have the patient clench and relax may be triggers for pain and should be avoided.
the jaw and eyes.
c. identify trigger zones by lightly Cognitive Level: Application Text Reference: p. 1583
touching the affected side. Nursing Process: Assessment NCLEX: Physiological In-
d. gently palpate the face to com- tegrity
pare skin temperature bilaterally.
3. 3. A patient with trigeminal neural- Correct Answer: D
gia has a glycerol rhizotomy. During Rationale: Because withdrawal from social activities
a follow-up visit after the rhizotomy, is a common manifestation of trigeminal neuralgia,
the nurse will evaluate that the pa- enjoyment of social activities indicates successful re-
tient has had a successful outcome duction of symptoms. Glycerol rhizotomy does not
for the surgery if the patient damage the corneal reflex or motor functions of the
actualstudy Page 1 of 40
, Nervous System NCLEX
Nervous System NCLEX
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a. uses an eye shield at night to pro- trigeminal nerve, so there is no need to use an eye
tect the cornea from injury. shield, do facial exercises, or take precautions with
b. develops and implements a daily chewing.
routine of facial exercises.
c. is careful to chew foods on the Cognitive Level: Application Text Reference: pp.
unaffected side of the mouth. 1583-1584
d. talks about enjoying social activi- Nursing Process: Evaluation NCLEX: Physiological In-
ties with family and friends. tegrity
4. 4. When the nurse is planning care Correct Answer: B
for a hospitalized patient who is Rationale: The patient with an acute episode of
experiencing an acute episode of trigeminal neuralgia may be unwilling to eat or drink,
trigeminal neuralgia, an appropri- so assessment of nutritional and hydration status is
ate action to include is important. Because stimulation by touch is the precip-
a. teach facial and jaw relaxation itating factor for pain, relaxation of the facial muscles
techniques. will not improve symptoms. Application of ice is likely
b. assess intake and output and di- to precipitate pain. The patient will not want to engage
etary intake. in conversation, which may precipitate attacks.
c. apply ice packs for no more than
20 minutes. Cognitive Level: Application Text Reference: p. 1583
d. spend time at the bedside talking Nursing Process: Planning NCLEX: Physiological In-
with the patient. tegrity
5. 5. When teaching patients who are Correct Answer: A
at risk for Bell's palsy because of Rationale: Pain or herpes lesions near the ear may
previous herpes simplex infection, indicate the onset of Bell's palsy and rapid corticos-
which information should the nurse teroid treatment may reduce the duration of Bell's
include? palsy symptoms. Antiviral therapy for herpes simplex
a. "You should call the doctor if pain does not reduce the risk for Bell's palsy. Corticosteroid
or herpes lesions occur near the therapy will be most effective in reducing symptoms
ear." if started before paralysis is complete but will still be
b. "Treatment of herpes with antivi- somewhat effective when started later. Facial exercises
actualstudy Page 2 of 40
, Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
ral agents will prevent development do not prevent Bell's palsy.
of Bell's palsy."
c. "Medications to treat Bell's palsy Cognitive Level: Application Text Reference: p. 1585
work only if started before paralysis Nursing Process: Implementation NCLEX: Physiologi-
onset." cal Integrity
d. "You may be able to prevent Bell's
palsy by doing facial exercises regu-
larly."
6. 6. A patient with Bell's palsy refus- Correct Answer: A
es to eat while others are present Rationale: The patient's desire for privacy should be
because of embarrassment about respected to encourage adequate nutrition and re-
drooling. The best response by the duce patient embarrassment. Liquid supplements will
nurse to the patient's behavior is to reduce the patient's enjoyment of the taste of food.
a. respect the patient's desire and It would be inappropriate for the nurse to discuss
arrange for privacy at mealtimes. the patient's embarrassment with visitors unless the
b. offer the patient liquid nutritional patient wishes to share this information. Chewing on
supplements at frequent intervals. the unaffected side of the mouth will enhance nutri-
c. discuss the patient's concerns tion and enjoyment of food but will not decrease the
with visitors who arrive at meal- drooling.
times.
d. teach the patient to chew food on Cognitive Level: Application Text Reference: p. 1585
the unaffected side of the mouth. Nursing Process: Implementation NCLEX: Psychoso-
cial Integrity
7. 7. A patient with Guillain-Barré syn- Correct Answer: B
drome asks the nurse what has Rationale: Guillain-Barré syndrome is believed to re-
caused the disease. In responding sult from an immunologic reaction that damages the
to the patient, the nurse explains myelin sheath of the peripheral nerves. Acute infec-
that Guillain-Barré syndrome tion or inflammation of the nerves is not a cause.
a. results from an acute infection The peripheral nerves are not destroyed and do not
and inflammation of the peripheral degenerate.
actualstudy Page 3 of 40
, Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
nerves.
b. is due to an immune reaction that Cognitive Level: Comprehension Text Reference: pp.
attacks the covering of the periph- 1585-1586
eral nerves. Nursing Process: Implementation NCLEX: Physiologi-
c. is caused by destruction of the cal Integrity
peripheral nerves after exposure to
a viral infection.
d. results from degeneration of the
peripheral nerve caused by viral at-
tacks.
8. 8. A 24-year-old patient is hospital- Correct Answer: D
ized with the onset of Guillain-Barré Rationale: The most serious complication of Guil-
syndrome. During this phase of the lain-Barré syndrome is respiratory failure, and the
patient's illness, the most essential nurse should monitor respiratory function continu-
assessment for the nurse to carry ously. The other assessments will also be included in
out is nursing care, but they are not as important as respi-
a. monitoring the cardiac rhythm ratory assessment.
continuously.
b. determining the level of con- Cognitive Level: Comprehension Text Reference: p.
sciousness q2hr. 1586
c. evaluating sensation and Nursing Process: Assessment NCLEX: Physiological In-
strength of the extremities. tegrity
d. performing constant evaluation
of respiratory function.
9. 9. When caring for a patient who Correct Answer: B
has Guillain-Barré syndrome, which Rationale: Drooling indicates decreased ability to
assessment data obtained by the swallow, which places the patient at risk for aspiration
nurse will require the most immedi- and requires rapid nursing and collaborative actions
ate action? such as suctioning and possible endotracheal intuba-
a. The patient complains of severe tion. The foot pain should be treated with appropriate
actualstudy Page 4 of 40
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
1. 1. When assessing a patient with Correct Answer: D
newly diagnosed trigeminal neural- Rationale: The major clinical manifestation of trigem-
gia, the nurse will ask the patient inal neuralgia is severe facial pain that is triggered
about by cutaneous stimulation of the nerve. Ptosis, loss of
a. triggers that lead to facial pain. taste, and numbness are not characteristics of trigem-
b. visual problems caused by pto- inal neuralgia, although ptosis and numbness may oc-
sis. cur after therapy, and poor appetite may be associated
c. poor appetite caused by a loss of with pain stimulated by eating.
taste.
d. decreased sensation on the af- Cognitive Level: Application Text Reference: p. 1581
fected side. Nursing Process: Assessment NCLEX: Physiological In-
tegrity
2. 2. During assessment of the pa- Correct Answer: A
tient with a recurrence of symp- Rationale: Oral hygiene is frequently neglected be-
toms of trigeminal neuralgia, the cause of fear of triggering facial pain. Having the
nurse should patient clench the facial muscles will not be useful
a. examine the mouth and teeth because the sensory branches of the nerve are affect-
thoroughly. ed by trigeminal neuralgia. Light touch and palpation
b. have the patient clench and relax may be triggers for pain and should be avoided.
the jaw and eyes.
c. identify trigger zones by lightly Cognitive Level: Application Text Reference: p. 1583
touching the affected side. Nursing Process: Assessment NCLEX: Physiological In-
d. gently palpate the face to com- tegrity
pare skin temperature bilaterally.
3. 3. A patient with trigeminal neural- Correct Answer: D
gia has a glycerol rhizotomy. During Rationale: Because withdrawal from social activities
a follow-up visit after the rhizotomy, is a common manifestation of trigeminal neuralgia,
the nurse will evaluate that the pa- enjoyment of social activities indicates successful re-
tient has had a successful outcome duction of symptoms. Glycerol rhizotomy does not
for the surgery if the patient damage the corneal reflex or motor functions of the
actualstudy Page 1 of 40
, Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
a. uses an eye shield at night to pro- trigeminal nerve, so there is no need to use an eye
tect the cornea from injury. shield, do facial exercises, or take precautions with
b. develops and implements a daily chewing.
routine of facial exercises.
c. is careful to chew foods on the Cognitive Level: Application Text Reference: pp.
unaffected side of the mouth. 1583-1584
d. talks about enjoying social activi- Nursing Process: Evaluation NCLEX: Physiological In-
ties with family and friends. tegrity
4. 4. When the nurse is planning care Correct Answer: B
for a hospitalized patient who is Rationale: The patient with an acute episode of
experiencing an acute episode of trigeminal neuralgia may be unwilling to eat or drink,
trigeminal neuralgia, an appropri- so assessment of nutritional and hydration status is
ate action to include is important. Because stimulation by touch is the precip-
a. teach facial and jaw relaxation itating factor for pain, relaxation of the facial muscles
techniques. will not improve symptoms. Application of ice is likely
b. assess intake and output and di- to precipitate pain. The patient will not want to engage
etary intake. in conversation, which may precipitate attacks.
c. apply ice packs for no more than
20 minutes. Cognitive Level: Application Text Reference: p. 1583
d. spend time at the bedside talking Nursing Process: Planning NCLEX: Physiological In-
with the patient. tegrity
5. 5. When teaching patients who are Correct Answer: A
at risk for Bell's palsy because of Rationale: Pain or herpes lesions near the ear may
previous herpes simplex infection, indicate the onset of Bell's palsy and rapid corticos-
which information should the nurse teroid treatment may reduce the duration of Bell's
include? palsy symptoms. Antiviral therapy for herpes simplex
a. "You should call the doctor if pain does not reduce the risk for Bell's palsy. Corticosteroid
or herpes lesions occur near the therapy will be most effective in reducing symptoms
ear." if started before paralysis is complete but will still be
b. "Treatment of herpes with antivi- somewhat effective when started later. Facial exercises
actualstudy Page 2 of 40
, Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
ral agents will prevent development do not prevent Bell's palsy.
of Bell's palsy."
c. "Medications to treat Bell's palsy Cognitive Level: Application Text Reference: p. 1585
work only if started before paralysis Nursing Process: Implementation NCLEX: Physiologi-
onset." cal Integrity
d. "You may be able to prevent Bell's
palsy by doing facial exercises regu-
larly."
6. 6. A patient with Bell's palsy refus- Correct Answer: A
es to eat while others are present Rationale: The patient's desire for privacy should be
because of embarrassment about respected to encourage adequate nutrition and re-
drooling. The best response by the duce patient embarrassment. Liquid supplements will
nurse to the patient's behavior is to reduce the patient's enjoyment of the taste of food.
a. respect the patient's desire and It would be inappropriate for the nurse to discuss
arrange for privacy at mealtimes. the patient's embarrassment with visitors unless the
b. offer the patient liquid nutritional patient wishes to share this information. Chewing on
supplements at frequent intervals. the unaffected side of the mouth will enhance nutri-
c. discuss the patient's concerns tion and enjoyment of food but will not decrease the
with visitors who arrive at meal- drooling.
times.
d. teach the patient to chew food on Cognitive Level: Application Text Reference: p. 1585
the unaffected side of the mouth. Nursing Process: Implementation NCLEX: Psychoso-
cial Integrity
7. 7. A patient with Guillain-Barré syn- Correct Answer: B
drome asks the nurse what has Rationale: Guillain-Barré syndrome is believed to re-
caused the disease. In responding sult from an immunologic reaction that damages the
to the patient, the nurse explains myelin sheath of the peripheral nerves. Acute infec-
that Guillain-Barré syndrome tion or inflammation of the nerves is not a cause.
a. results from an acute infection The peripheral nerves are not destroyed and do not
and inflammation of the peripheral degenerate.
actualstudy Page 3 of 40
, Nervous System NCLEX
Nervous System NCLEX
Study online at https://quizlet.com/_1o4zx5
nerves.
b. is due to an immune reaction that Cognitive Level: Comprehension Text Reference: pp.
attacks the covering of the periph- 1585-1586
eral nerves. Nursing Process: Implementation NCLEX: Physiologi-
c. is caused by destruction of the cal Integrity
peripheral nerves after exposure to
a viral infection.
d. results from degeneration of the
peripheral nerve caused by viral at-
tacks.
8. 8. A 24-year-old patient is hospital- Correct Answer: D
ized with the onset of Guillain-Barré Rationale: The most serious complication of Guil-
syndrome. During this phase of the lain-Barré syndrome is respiratory failure, and the
patient's illness, the most essential nurse should monitor respiratory function continu-
assessment for the nurse to carry ously. The other assessments will also be included in
out is nursing care, but they are not as important as respi-
a. monitoring the cardiac rhythm ratory assessment.
continuously.
b. determining the level of con- Cognitive Level: Comprehension Text Reference: p.
sciousness q2hr. 1586
c. evaluating sensation and Nursing Process: Assessment NCLEX: Physiological In-
strength of the extremities. tegrity
d. performing constant evaluation
of respiratory function.
9. 9. When caring for a patient who Correct Answer: B
has Guillain-Barré syndrome, which Rationale: Drooling indicates decreased ability to
assessment data obtained by the swallow, which places the patient at risk for aspiration
nurse will require the most immedi- and requires rapid nursing and collaborative actions
ate action? such as suctioning and possible endotracheal intuba-
a. The patient complains of severe tion. The foot pain should be treated with appropriate
actualstudy Page 4 of 40
