Exam 3 Chapter 69
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? Respiratory Gastrointestinal Urinary Skin
Respiratory
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? Increased ability to sleep Relief from constipation Relief from pain Reduced muscle spasticity
Reduced muscle spasticity
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Musculoskeletal Integumentary Hepatic Renal
Renal
A frontal lobe brain abscess produces which manifestation? Localized headache Seizures Ataxia Nystagmus
Seizures
A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? Bell's palsy Trigeminal neuralgia Migraine headache Angina pectoris
Trigeminal neuralgia
A client is hospitalized with Guillain-Barré syndrome. Which nursing assessment finding is most significant? Warm, dry skin Urine output of 40 ml/hour Soft, nondistended abdomen Uneven, labored respirations
Uneven, labored respirations
A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? Vision changes Absent deep tendon reflexes Tremors at rest Flaccid muscles
Vision changes
A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a positive edrophonium (Tensilon) test. Kernig's sign. a positive sweat chloride test. Brudzinski's sign.
a positive edrophonium (Tensilon) test.
When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? "Avoid taking daytime naps." "Avoid hot baths and showers." "Limit your fruit and vegetable intake." "Restrict fluid intake to 1,500 ml/day."
"Avoid hot baths and showers."
A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? "You will have a steady and gradual decline in function." "Your type of MS is the least common, making it difficult to manage." "You must avoid stress and extreme fatigue, because these can trigger a relapse." "You should take your medications only during times of relapse."
"You must avoid stress and extreme fatigue, because these can trigger a relapse."
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? Place the patient in the supine position. Administer diphenhydramine (Benadryl) for the allergic reaction. Administer atropine to control the side effects of edrophonium. Call the rapid response team because the patient is preparing to arrest.
Administer atropine to control the side effects of edrophonium.
The nurse is providing education to a group of young people about the dangers of tattoos and body piercings. Which of the following would the nurse describe as a possible result of a tongue piercing? c Strep throat infection Otitis media Damage to cranial nerve V
Brain abscess
Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis? Preventing renal insufficiency c Maintaining hemodynamic stability and adequate cardiac output Preventing muscular atrophy
Controlling seizures and increased intracranial pressure
A client is being admitted to the neurologic ICU with suspected herpes simplex virus encephalitis. What nursing action best addresses the client's complaints of headache? Initiating a patient-controlled analgesia (PCA) of morphine sulfate Administering hydromorphone IV as needed Dimming the lights and reducing stimulation Distracting the client with activity
Dimming the lights and reducing stimulation
When caring for a client with trigeminal neuralgia, which intervention has the highest priority? Providing emotional support while the client adjusts to changes in his physical appearance Monitoring intake and output Assisting with ambulation Encouraging the client to bathe with care
Encouraging the client to bathe with care
A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients? Gag reflex and bowel sounds Condition of skin Respiratory status Urinary output and capillary refill
Gag reflex and bowel sounds
A nurse is assisting with the assessment of a client with suspected brain abscess. Which of the following findings would be consistent with such an abscess in the frontal lobe of the brain? Select all that apply. Hemiparesis Seizures Expressive aphasia Changes in vision Nystagmus
Hemiparesis Seizures Expressive aphasia
Which is the most common cause of acute encephalitis in the United States? Western equine virus Herpes simplex virus West Nile virus St. Louis virus
Herpes simplex virus
The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? Level of consciousness Peripheral pulses Sensory perception Crackles bilaterally
Level of consciousness
The diagnosis of multiple sclerosis is based on which test? Cerebrospinal fluid (CSF) electrophoresis Magnetic resonance imaging (MRI) Evoked potential studies Neuropsychological testing
Magnetic resonance imaging (MRI)
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? Parkinson disease Huntington disease Creutzfeldt-Jakob disease Multiple sclerosis
Multiple sclerosis
The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis? Muscle weakness and hyporeflexia of the lower extremities Fever and cough Hyporeflexia and skin rash Ptosis and muscle weakness of upper extremities
Muscle weakness and hyporeflexia of the lower extremities
A patient diagnosed with multiple sclerosis (MS) has ataxia. Which of the following medications could be used to treat this clinical manifestation? Neurontin Baclofen Dantrium Valium
Neurontin
The most common cause of cholinergic crisis includes which of the following? Overmedication Infection Undermedication Compliance with medication
Overmedication
Which is often the most disabling clinical manifestation of multiple sclerosis? Pain Fatigue Spasticity Ataxia
Fatigue
The diagnosis of multiple sclerosis is based on which test? CSF electrophoresis Magnetic resonance imaging Evoked potential studies Neuropsychological testing
Magnetic resonance imaging
Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support
Assessing respiratory effort
A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? Reduction in the appearance of new lesions on the MRI Decreased muscle spasms in the lower extremities Increased muscle strength in the upper extremities Decreased severity and duration of exacerbations
Decreased muscle spasms in the lower extremities
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? Ambenonium (Mytelase) Pyridostigmine (Mestinon) Edrophonium (Tensilon) Carbachol (Carboptic)
Edrophonium (Tensilon)
A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test? Cyclosporine (Sandimmune) Edrophonium (Tensilon) Immunoglobulin G (Iveegam EN) Azathioprine (Imuran)
Edrophonium (Tensilon)
Bell's palsy is a paralysis of which of the following cranial nerves? Facial Trigeminal Optic Otic
Facial
A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside? Sphygmomanometer Padded tongue blade Nasal cannula and oxygen Suction machine with catheters
Suction machine with catheters
A client with fungal encephalitis receiving amphotericin B reports fever, chills, and body aches. The nurse knows that these symptoms indicate renal toxicity and a worsening condition. are primarily associated with infection with Coccidioides immitis and Aspergillus. indicate the need for immediate blood and cerebral spinal fluid (CSF) cultures. may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin.
may be controlled by the administration of diphenhydramine and acetaminophen approximately 30 minutes before administration of the amphotericin.
The primary arthropod vector in North America that transmits encephalitis is the tick. horse. mosquito. flea.
mosquito.
A client is admitted through the ED with suspected St. Louis encephalitis. The unique clinical feature of St. Louis encephalitis will make what nursing action a priority? Serial assessments of hemoglobin levels Blood glucose monitoring Close monitoring of fluid balance Assessment of pain along dermatomes
Close monitoring of fluid balance
Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? Apply an eye patch to the right eye. Exercise the right eye twice a day. Administer eye drops as needed. Place needed items on the right side.
Apply an eye patch to the right eye.
The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform? Apply warm packs to the affected area. Relax in a hot bath. Exercise following a circuit training regimen. Avoid swimming and any weight-bearing activity.
Apply warm packs to the affected area.
The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? Impaired skin integrity Cognitive deficits Hemorrhage Autonomic dysfunction
Autonomic dysfunction
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which is the priority nursing action? Assess facial weakness 5 minutes after injection. Ensure atropine is readily available. Administer edrophonium chloride per orders. Document the results.
Ensure atropine is readily available.
While performing an initial nursing assessment on a client admitted with suspected tic douloureux (trigeminal neuralgia), for which of the following would the nurse expect to observe? Facial pain in the areas of the fifth cranial nerve Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Fatigue and depression
Facial pain in the areas of the fifth cranial nerve
The critical care nurse is caring for 25-year-old man admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? Maintaining the client's functional independence Providing health education Monitoring neurologic status closely Promoting mobility
Monitoring neurologic status closely
Which is the primary vector of arthropod-borne viral encephalitis in North America? Birds Spiders Mosquitoes Ticks
Mosquitoes
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord? Parkinson disease Huntington disease Creutzfeldt-Jakob disease Multiple sclerosis
Multiple sclerosis
The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? An elevated acetylcholine receptor antibody titer Episodes of muscle fasciculations IV administration of edrophonium Oligoclonal bands
Oligoclonal bands
Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. Pain Fatigue Spasticity Aphasia Depression Numbness
Pain Fatigue Spasticity Depression Numbness
A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? Assess for facial weakness. Initiate seizure precautions. Assess visual acuity. Ensure that client takes nothing by mouth.
Initiate seizure precautions.
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the potential complications of the disorder, what should the nurse keep always ready at the bedside? Nebulizer and thermometer Intubation tray and suction apparatus Blood pressure apparatus Incentive spirometer
Intubation tray and suction apparatus
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has an ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside? Nebulizer and thermometer Intubation tray and suction apparatus Blood pressure apparatus Incentive spirometer
Intubation tray and suction apparatus
The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? MS is a progressive demyelinating disease of the nervous system. MS usually occurs more frequently in men. MS typically has an acute onset. MS is sometimes caused by a bacterial infection.
MS is a progressive demyelinating disease of the nervous system.
The nurse is performing an initial assessment on a client who is admitted to rule out myasthenia gravis. Which of the following findings would the nurse expect to observe? Ptosis and diplopia Muscle weakness and hyporeflexia of the lower extremities Difficulty with urination Facial distortion and pain
Ptosis and diplopia
The nurse caring for a client diagnosed with Guillain-Barré syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the client should reflect the possibility of what sign or symptom of the disease? Intermittent hearing loss Tinnitus Tongue enlargement Vocal paralysis
Vocal paralysis
A client with a neurologic impairment reports having problems with constipation. Which foods might the nurse recommend? vegetables ice cream meat white rice
vegetables
A client with metastatic cancer has developed trigeminal neuralgia and is taking carbamazepine for pain relief. What principle applies to the administration of this medication? Carbamazepine is not known to have serious adverse effects. The client should be monitored for bone marrow depression. Side effects of the medication include renal dysfunction. The medication should be first taken in the maximum dosage form to be effective.
The client should be monitored for bone marrow depression.
A nurse is providing education to a client with newly diagnosed multiple sclerosis (MS). Which of the following will the nurse include? Avoid hot temperatures. Avoid physical activity. Take moderate amounts of alcohol. Avoid analgesic medication.
Avoid hot temperatures.
The nurse is discharging a client home after surgery for trigeminal neuralgia. What advice should the nurse provide to this client in order to reduce the risk of injury? Avoid watching television or using a computer for more than 1 hour at a time. Use over-the-counter antibiotic eye drops for at least 14 days. Avoid rubbing the eye on the affected side of the face. Rinse the eye on the affected side with normal saline daily for 1 week.
Avoid rubbing the eye on the affected side of the face.
Which is the most common cause of acute encephalitis in the United States? Western equine bacteria Herpes simplex virus (HSV) Lyme Disease Human immunodeficiency virus (HIV)
Herpes simplex virus (HSV)
Which diagnostic test is used for early diagnosis of HSV-1 encephalitis? Lumbar puncture (LP) Polymerase chain reaction (PCR) Electroencephalography (EEG) Magnetic resonance imaging (MRI)
Polymerase chain reaction (PCR)
The nurse is caring for a 77-year-old woman with MS. She states that she is very concerned about the progress of her disease and what the future holds. The nurse should know that elderly clients with MS are known to be particularly concerned about what variables? Select all that apply. Possible nursing home placement Pain associated with physical therapy Increasing disability Becoming a burden on the family Loss of appetite
Possible nursing home placement Increasing disability Becoming a burden on the family
A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? Administer bronchodilators as ordered. Remind the client of the importance of deep breathing and coughing exercises. Prepare to assist with intubation. Administer supplementary oxygen by nasal cannula.
Prepare to assist with intubation.
The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client? Suctioning secretions Facilitating ABG analysis Providing ventilatory assistance Administering tube feedings
Providing ventilatory assistance
Which of the following is the first-line therapy for myasthenia gravis (MG)? Pyridostigmine bromide (Mestinon) Deltasone (Prednisone) Azathioprine (Imuran) Lioresal (Baclofen)
Pyridostigmine bromide (Mestinon)
A patient diagnosed with MS 2 years ago has been admitted to the hospital with another relapse. The previous relapse was followed by a complete recovery with the exception of occasional vertigo. What type of MS does the nurse recognize this patient most likely has? Benign Primary progressive Relapsing-remitting (RR) Disabling
Relapsing-remitting (RR)
A 48-year-old client has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis? The client will likely require lifelong treatment with anticholinergic medications. The client has a disproportionate risk of developing myasthenia gravis later in life. The client needs to be assessed for MS. The disease is self-limiting and the client will achieve pain relief over time.
The client needs to be assessed for MS.
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following? "Have you experienced any viral infections in the last month?" "Have you experienced any ptosis in the last few weeks?" "Have you had difficulty with urination in the last 6 weeks?" "Have you developed any new allergies in the last year?"
"Have you experienced any viral infections in the last month?"
A client with fungal encephalitis receiving IV amphotericin B reports fever, chills, and body aches. What action by the nurse is appropriate? Assess laboratory values for renal insufficiency. Stop the infusion immediately. Notify the physician and prepare for a lumbar puncture to obtain CSF cultures. Administer diphenhydramine and acetaminophen per orders.
Administer diphenhydramine and acetaminophen per orders.
A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes Flexor spasm, clonus, and negative Babinski reflex Blurred vision, intention tremor, and urinary hesitancy Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Blurred vision, intention tremor, and urinary hesitancy
The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning? Decreased pulse rate, respirations of 20 breaths/minute Increased pulse rate, adventitious breath sounds Increased pulse rate, respirations of 16 breaths/minute Decreased pulse rate, abdominal breathing
Increased pulse rate, adventitious breath sounds
A patient with myasthenia gravis is in the hospital for treatment of pneumonia. The patient informs the nurse that it is very important to take pyridostigmine bromide (Mestinon) on time. The nurse gets busy and does not administer the medication until after breakfast. What outcome will the patient have related to this late dose? The muscles will become fatigued and the patient will not be able to chew food or swallow pills. There should not be a problem, since the medication was only delayed by about 2 hours. The patient will go into cardiac arrest. The patient will require a double dose prior to lunch.
The muscles will become fatigued and the patient will not be able to chew food or swallow pills.
A client in a long-term nursing facility has severe dysphagia. Which of the following would best assist this client in preventing further complications? Placement of a feeding tube Placement of a urinary catheter Placement of a colostomy tube Placement of a tracheostomy tube
Placement of a feeding tube
Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis? Polymerase chain reaction (PCR) Electroencephalogram (EEG) Cerebrospinal fluid (CSF) exam Lumbar puncture
Polymerase chain reaction (PCR)
The nurse is performing an initial assessment on a client admitted with a possible brain abscess. Which of the following would the nurse most likely find? Headache that is worse in the morning Ptosis that is more pronounced at the end of the day Diplopia that is constant Nuchal rigidity
Headache that is worse in the morning
A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: genetic dysfunction. upper and lower motor neuron lesions. decreased conduction of impulses in an upper motor neuron lesion. a lower motor neuron lesion.
a lower motor neuron lesion.
Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at preventing renal insufficiency. controlling seizures and increased intracranial pressure. maintaining hemodynamic stability and adequate cardiac output. preventing muscular atrophy.
controlling seizures and increased intracranial pressure.
The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? Genetic dysfunction Upper and lower motor neuron lesions Decreased conduction of impulses in an upper motor neuron lesion A lower motor neuron lesion
A lower motor neuron lesion
Bell palsy is a disorder of which cranial nerve? Trigeminal (V) Vestibulocochlear (VIII) Facial (VII) Vagus (X)
Facial (VII)
A provider prescribes a disease-modifying drug for a patient with relapsing-remitting MS. The nurse advises the patient that the drug has to be taken subcutaneously on a daily basis, and it may take 6 months for evidence of any response. Which of the following is the medication most likely prescribed in this scenario? Avonex Betaseron Copaxone Novantrone
Copaxone
A middle-aged woman has sought care from her primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the woman to seek care? Cognitive declines Personality changes Contractures Difficulty in coordination
Difficulty in coordination
A client diagnosed with Bell palsy is having decreased sensitivity to touch of the involved nerve. What should the nurse recommend to prevent atrophy of the muscles? Blowing up balloons Deliberately frowning Smiling repeatedly Whistling
Whistling
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: take a hot bath. rest in an air-conditioned room. increase the dose of muscle relaxants. avoid naps during the day.
rest in an air-conditioned room.
Which of the following is considered a central nervous system (CNS) disorder? Multiple sclerosis Guillain-Barré Myasthenia gravis Bell's palsy
Multiple sclerosis
A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching? "You'll continue to experience progressive muscle weakness and sensory deficits." "You'll need to take edrophonium (Tensilon) to treat the disease." "The disease is a disorder of motor and sensory dysfunction." "This disease doesn't cause sensory impairment."
"This disease doesn't cause sensory impairment."
At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.
45
Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine Acetylcholine Gamma-aminobutyric acid
Acetylcholine
A 34-year-old patient is diagnosed with relapsing-remitting MS. The nurse explains to the patient's family that they should expect: Acute attacks with full recovery or residual deficit upon recovery. Progressive disability from onset. Acute attacks followed by progression at a variable rate. Progression with clear relapses with or without recovery.
Acute attacks with full recovery or residual deficit upon recovery.
A client with herpes simplex virus encephalitis (HSV) has been admitted to the ICU. What medication would the nurse expect the health care provider to order for the treatment of this disease process? Cyclosporine Acyclovir Cyclobenzaprine Ampicillin
Acyclovir
To alleviate pain associated with trigeminal neuralgia, a client is taking carbamazepine. What health education should the nurse provide to the client before initiating this treatment? Concurrent use of calcium supplements is contraindicated. Blood levels of the drug must be monitored. The drug is likely to cause hyperactivity and agitation. Carbamazepine can cause tinnitus during the first few days of treatment.
Blood levels of the drug must be monitored.
A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements? Antibodies are removed from the plasma. The thymus gland is removed. Immune globulin is given intravenously. Mestinon therapy is initiated.
Antibodies are removed from the plasma.
A client diagnosed with Bell palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? Applying a protective eye shield at night Chewing on the affected side to prevent unilateral neglect Avoiding the use of analgesics whenever possible Avoiding brushing the teeth
Applying a protective eye shield at night
The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? Approximately 60% to 75% of clients recover completely. Only a very small percentage (5% to 8%) of clients recover completely. Usually 100% of clients recover completely. No one with Guillain-Barre syndrome recovers completely.
Approximately 60% to 75% of clients recover completely.
The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? Assess the respiratory rate and oxygen saturation. Assess the blood pressure and heart rate. Assess the peripheral pulses. Listen to the bowel sounds.
Assess the blood pressure and heart rate.
A patient suspected of having Guillain-Barré syndrome has had a lumbar puncture for cerebrospinal fluid (CSF) evaluation. When reviewing the laboratory results, what does the nurse find that is diagnostic for this disease? Glucose in the CSF Elevated protein levels in the CSF Red blood cells present in the CSF White blood cells in the CSF
Elevated protein levels in the CSF
The nurse is developing a plan of care for a client newly diagnosed with Bell palsy. The nurse's plan of care should address what characteristic manifestation of this disease? Tinnitus Facial paralysis Pain at the base of the tongue Diplopia
Facial paralysis
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of myasthenia gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this client? All at one time, to provide a longer rest period Before meals, to stimulate her appetite In the morning, with frequent rest periods Before bedtime, to promote rest
In the morning, with frequent rest periods
The clinic nurse is caring for a client with a recent diagnosis of myasthenia gravis. The client has begun treatment with pyridostigmine bromide. What change in status would most clearly suggest a therapeutic benefit of this medication? Increased muscle strength Decreased pain Improved GI function Improved cognition
Increased muscle strength
The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscles spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario? Valium Zanaflex Lioresal Dantrium
Lioresal
A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? Arrange for the client to receive a low residue diet. Position the client upright during feeding. Suction the client following each meal. Withhold liquids until the client has finished eating.
Position the client upright during feeding.
Which reflects basic nursing measures in the care of the client with viral encephalitis? Providing comfort measures Administering narcotic analgesics Administering amphotericin B Monitoring cardiac output
Providing comfort measures
A client diagnosed with myasthenia gravis has been hospitalized to receive therapeutic plasma exchange (TPE) for a myasthenic exacerbation. The nurse should anticipate what therapeutic response? Permanent improvement after 4 to 6 months of treatment Symptom improvement that lasts a few weeks after TPE ceases Permanent improvement after 60 to 90 treatments Gradual improvement over several months
Symptom improvement that lasts a few weeks after TPE ceases
Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Tensilon test Computed tomography (CT) scan Electromyogram (EMG) Serum studies
Tensilon test
The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response? "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." "I know you understand that nerve cells do not remyelinate, so the physician is the best one to answer your question." "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."
"Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease."
A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? Call the physician and prepare for intubation. Explain the progression of the syndrome. Assess lung sounds. Encourage the client to cough.
Call the physician and prepare for intubation.
A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems? Frontal lobe abscess Temporal lobe abscess Cerebellar abscess Wernicke's abscess
Cerebellar abscess
The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine? Administer the medication rapidly over 15 minutes with 100 mL of normal saline. Dilute the medicine in 500 mL of lactated Ringer's solution. Administer via slow IV over 1 hour. Administer in a drip over 4 hours.
Dilute the medicine in 500 mL of lactated Ringer's solution. Administer via slow IV over 1 hour.
The nurse is planning discharge education for a client with trigeminal neuralgia. The nurse knows to include information about factors that precipitate an attack. What would the nurse be correct in teaching the client to avoid? Washing his face Exposing his skin to sunlight Using artificial tears Drinking large amounts of fluids
Washing his face
A client is receiving mitoxantrone for treatment of secondary progressive multiple sclerosis (MS). This client should be closely monitored for mood changes and fluid and electrolyte alterations. renal insufficiency. hypoxia. leukopenia and cardiac toxicity.
leukopenia and cardiac toxicity.
The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for signs and symptoms of cardiac insufficiency. signs of relapse. signs of improvement in the patient's condition. renal complications related to acyclovir therapy.
renal complications related to acyclovir therapy.
The nurse is caring for a patient in the emergency department with an onset of pain related to trigeminal neuralgia. What subjective data stated by the patient does the nurse determine triggered the paroxysms of pain? "I was sitting at home watching television." "I was putting my shoes on." "I was brushing my teeth." "I was taking a bath."
"I was brushing my teeth."
The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? "I will take hot tub baths to decrease spasms." "I should participate in non-weight-bearing exercises." "I will stretch daily as directed by the physical therapist." "The exercises should be completed quickly to reduce fatigue."
"I will stretch daily as directed by the physical therapist."
A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "The paralysis caused by this disease is temporary." "You'll be permanently paralyzed; however, you won't have any sensory loss." "It must be hard to accept the permanency of your paralysis." "You'll first regain use of your legs and then your arms."
"The paralysis caused by this disease is temporary."
The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? "Don't worry; your child will be fine." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." "It's too early to give a prognosis."
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? A disorder in which the body has too many immunoglobulins A disorder in which histocompatible cells attack the immunoglobulins A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" A disorder in which the body does not have enough immunoglobulins
A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self"
In myasthenia gravis (MG), there is a decrease in the number of receptor sites of which neurotransmitter? Acetylcholine Epinephrine Norepinephrine Dopamine
Acetylcholine
Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Dopamine Acetylcholine GABA
Acetylcholine
The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? Medications must be taken on time. Medications can be taken whenever convenient. Medications are best taken while the client is in a reclining position. There is no conflict with the disorder and dental work.
Medications must be taken on time.
A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis? Use pressure-relieving devices when the client is in bed or in a wheelchair. Change body position every 2 hours. Help the client perform range-of-motion (ROM) exercises every 8 hours. Use a footboard and trochanter rolls.
Help the client perform range-of-motion (ROM) exercises every 8 hours.
The nurse is caring for a patient with MS who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply. Have the patient take a hot tub bath to allow muscle relaxation. Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises Assist with a rigorous exercise program to prevent contractures.
Demonstrate daily muscle stretching exercises. Apply warm compresses to the affected areas. Allow the patient adequate time to perform exercises
The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Diplopia and ptosis Numbness Patchy blindness Loss of proprioception
Diplopia and ptosis
The nurse is caring for a client who is hospitalized with an exacerbation of MS. To ensure the client's safety, what nursing action should be performed? Ensure that suction apparatus is set up at the bedside. Pad the client's bed rails. Maintain bed rest whenever possible. Provide several small meals each day.
Ensure that suction apparatus is set up at the bedside.
A client with MS has been admitted to the hospital following an acute exacerbation. When planning the client's care, the nurse addresses the need to enhance the client's bladder control. What aspect of nursing care is most likely to meet this goal? Establish a timed voiding schedule. Avoid foods that change the pH of urine. Perform intermittent catheterization q6h. Administer anticholinergic drugs as prescribed.
Establish a timed voiding schedule.
The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? Facial distortion and pain Hyporeflexia and weakness of the lower extremities Ptosis and diplopia Fatigue and depression
Facial distortion and pain
The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? Encourage the client to void every hour. Order a low-residue diet. Provide total assistance with all ADLs. Instruct the client on daily muscle stretching.
Instruct the client on daily muscle stretching.
Which of the following are disease-modifying agents used in the treatment of multiple sclerosis (MS)? Select all that apply. Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone) Tizanidine (Zanaflex)
Interferon beta-1a (Rebif) Interferon beta-1b (Betaseron) Interferon beta-1a (Avonex) Glatiramer acetate (Copaxone)
The nurse is planning care for a client with Guillain-Barre syndrome. The priority client outcome would be which of the following? Maintains effective respirations and airway clearance Shows increasing mobility Receives adequate nutrition and hydration Demonstrates recovery of speech
Maintains effective respirations and airway clearance
The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? Taking a hot bath at least once daily Resting in an air-conditioned room whenever possible Increasing the dose of muscle relaxants Avoiding naps during the day
Resting in an air-conditioned room whenever possible
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin? Speeds nerve impulse transmission Carries message to the next nerve cell Represents building block of nervous system Acts as chemical messenger
Speeds nerve impulse transmission
A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Suggest applying cool compresses on the face several times a day to tighten the muscles. Inform the patient that the muscle function will return as soon as the virus dissipates. Tell the patient to smile every 4 hours.
Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). The care plan for this client reflects the client's problem eating due to jaw pain. To assist the client in meeting the adequate nutritional needs, what should the nurse suggest? Take small meals of soft consistency Increase the intake of calcium and proteins. Include additional servings of fruits and raw vegetables Include fish, liver, and chicken in diet
Take small meals of soft consistency
The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms.
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? Using the incentive spirometer as prescribed Maintaining the client on bed rest Providing aids to compensate for loss of vision Assessing frequently for loss of cognitive function
Using the incentive spirometer as prescribed
