MED/SURG CH 50

A patient in the plateau stage of Guillain-Barre syndrome is frustrated because there has not been any improvement in manifestations for 5 days. What should the nurse explain to the patient? a. The manifestations can last up to 2 weeks b. The manifestations can last up to 3 weeks c. The manifestations can last up to 6 months d. The manifestations can last up to 24 months

A GBS is divided into three stages. The second stage is the plateau stage, when symptoms are most severe but progression has stopped. It can last from 2 to 14 days. Patients may become discouraged if no improvement is evident. B. The first stage starts with the onset of symptoms and lasts until the progression of symptoms stops. This stage can last from 24 hours to 3 weeks. C. D. Axonal regeneration and remyelination occur during the third state, recovery. This stage lasts from 6 to 24 months and symptoms slowly improve

A patient with multiple sclerosis is unable to verbally communicate needs. Which approach should the nurse use to assess this patient for pain? a. Observe for grimacing or agitation b. Ask the patient to press the call light if pain is present c. Schedule pain medication every 4 hours around the clock d. Offer pain medication every shift with routine medications

A The patient may not be able to verbally state that pain is present. The nurse should assess the patient for nonverbal signs of pain or distress, such as restlessness, agitation, and grimacing. B. The patient might not be able to press the call light. C. D. Pain medication should not be routinely provided around the clock or with other medications without completing an adequate pain assessment.

The nurse is caring for a patient with post-polio syndrome. What should the nurse explain to the patient in preparation for discharge? (Select all that apply.) a. Engage in moderate exercise. b. Ensure an adequate amount of rest each day. c. Schedule periods of intense physical activity. d. Spend several hours each day in direct sunlight. e. Reduce the intake of high protein high fat foods.

A, B There is no specific therapeutic regimen for this disorder. Symptoms seem to be best controlled by rest and moderate exercise without pushing the limits of tolerance. C. Intense physical activity could exacerbate symptoms of the disorder. D. Sunlight is not an identified treatment for post-polio syndrome. E. High protein and high fat foods are not implicated in the development or treatment of this disorder.

After frequent examinations a patient is diagnosed with amyotrophic lateral sclerosis (ALS). Which test results should the nurse review as confirmation of this diagnosis? (Select all that apply.) a. Nerve biopsy b. Electroencephalogram c. Nerve conduction velocity d. Analysis of cerebrospinal fluid e. CT scan of the brain and spinal cord

A, B, C, D Diagnosis of ALS is made based on clinical symptoms. Additional tests such as nerve biopsy, electroencephalogram, nerve conduction velocity and CSF analysis may be done to rule out other conditions. E. CT scan of the brain and spinal cord are not used to diagnose ALS.

. The nurse is teaching a patient with myasthenia gravis how to recognize a cholinergic crisis. What manifestations should the nurse include in this teaching? (Select all that apply.) a. Diarrhea b. Salivation c. Vomiting d. Difficulty speaking e. Abdominal cramping f. Increased bronchial secretions

A, B, C, E, F Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal cramping, and emesis. A severe crisis has been described as liquid pouring out of every body orifice. D. Difficulty speaking is not a manifestation of a cholinergic crisis.

The nurse is explaining the difference between Bells palsy and trigeminal neuralgia to a nursing assistant. What should the nurse include as characteristics of Bells palsy? (Select all that apply.) a. Drooling b. Facial droop c. Sudden onset d. Airflow sensitivity e. Sensitivity to temperature f. Loss of taste over anterior part of tongue

A, B, F Patients with Bells palsy have a facial droop, variable symptom onset, changes in taste, and drooling. C. D. E. Patients with trigeminal neuralgia (TN) experience sudden onset and temperature and airflow sensitivity.

The nurse is caring for a patient who is being tested for possible myasthenia gravis (MG). Which early symptoms of myasthenia gravis should the nurse document in the medical record? (Select all that apply.) a. Ptosis b. Nausea c. Tremor d. Confusion e. Weakness f. Numbness of the extremities

A, E The hallmark of MG is increased muscle weakness during activity and improvement in muscle strength after rest. Patients often present with drooping of the eyelids (ptosis). F. Numbness and tingling of the extremities is characteristic of multiple sclerosis (MS), not MG. B. C. D. Nausea, tremor and confusion are not characteristics of MG.

The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). Which assessment findings should the nurse anticipate? (Select all that apply.) a. Hemiparesis b. Bradykinesia c. Pill-rolling tremor d. Ascending paralysis e. Progressive weakness f. Decreased coordination of extremities

ANS: E, F Primary symptoms of ALS include progressive muscle weakness and decreased coordination of arms, legs, and trunk. Atrophy of muscles and twitching (fasciculations) also occur. B. C. Pill-rolling tremor and bradykinesia are symptoms of Parkinsons disease. D. Ascending symptoms occur in Guillain-Barr syndrome. A. Paralysis on one side of the body occurs in strokes.

A patient with Bells palsy has lost 10 pounds since being diagnosed. Why should the nurse plan interventions to address the risk for nutrition problems? a. Appetite is diminished. b. Taste and chewing are affected. c. Nutrients are not absorbed efficiently. d. The patient may have difficulty preparing foods.

B Difficulty eating may cause the patient to eat less and lose weight. A, C, and D are not affected by Bells palsy.

A patient diagnosed with Guillain-Barr syndrome (GBS) asks how the disease developed since the patient rarely has an illness. What nursing response is the most accurate? a. No one knows what causes it. b. It may be an autoimmune reaction to a virus. c. It most often occurs as a result of a bacterial infection. d. It is usually hereditary. Does anyone in your family have it?

B GBS is believed to be caused by an autoimmune response to some type of viral infection or vaccination. A. No one does have an exact cause however this statement is not the most accurate. C. It is believed to occur after a viral infection. D. It is not hereditary.

The nurse is caring for a patient experiencing an acute exacerbation of multiple sclerosis (MS). Which pathophysiological change should the nurse recognize as causing the manifestations of MS? a. Myelin buildup in the central nervous system b. Demyelination and destruction of nerve fibers c. Gamma aminobutyric acid (GABA) deficiency

B In multiple sclerosis, the myelin sheath begins to break down or degenerates as a result of the activation of the bodys immune system. The nerve becomes inflamed and edematous. Nerve impulses to the muscles slow down. As the disease progresses, sclerosis or scar tissue damages the nerve. A. Myelin does not build up. C. GABA is an inhibitory neurotransmitter. D. Acetylcholine receptors are damaged in myasthenia gravis.

The nurse is helping a patient with trigeminal neuralgia with bathing. Which action should the nurse take when washing the patients face? a. Use hot water and antibacterial soap. b. Use lukewarm water and cotton balls. c. Use cold water to reduce inflammation. d. Use a washcloth to stimulate circulation.

B Lukewarm water and soft cotton may be less likely to exacerbate pain. A. C. D. A rough washcloth or temperature extremes can cause pain.

A patient is scheduled for a thymectomy. For which peripheral nervous system disorder should the nurse plan care for this patient? a. Multiple sclerosis (MS) b. Myasthenia gravis (MG) c. Guillain-Barr syndrome (GBS) d. Amyotrophic lateral sclerosis (ALS)

B No cure has been found for MG. Treatment is aimed at control of symptoms. Removal of the thymus gland (thymectomy) can decrease production of anticholinesterase (ACh) receptor antibodies and decrease symptoms in most patients. A. C. D. A thymectomy is not indicated in the treatment of MS, GBS, or ALS.

The nurse is preparing a patient with myasthenia gravis to undergo plasmapheresis. Which laboratory tests should the nurse verify and place on the medical record before the procedure? a. Urine analysis, urine protein, BUN, and creatinine b. Complete blood count, platelets, and clotting studies c. Creatinine phosphokinase, blood type, and electrolytes d. Electrolytes, blood urea nitrogen (BUN), creatinine, and albumin

B Plasmapheresis is used to remove the patients plasma and replace it with fresh plasma. Complete blood cell count, platelet count, and clotting studies are assessed prior to the procedure. A. B. D. Laboratory tests such as urinalysis, urine protein, BUN, creatinine, blood type, electrolytes, and albumin are not necessary before having a plasmapheresis.

The nurse is caring for a patient with an exacerbation of multiple sclerosis. Which medication should the nurse anticipate administering to this patient? a. Thyrotropin b. Pyridostigmine (Mestinon) c. Diphenhydramine (Benadryl) d. Adrenocorticotropic hormone (ACTH)

B Steroids such as ACTH, prednisone, and other corticotropic medications are given to decrease inflammation and edema of the neuron, which may relieve some symptoms. C. Benadryl is an antihistamine. B. Pyridostigmine (Mestinon) is used in myasthenia gravis. A. Thyrotropin stimulates release of thyroid hormone.

A patient with amyotrophic lateral sclerosis has difficulty swallowing and copious pulmonary secretions. What equipment should the nurse ensure is at the bedside at all times? a. Tissues b. Suction c. Oxygen d. Tongue blade

B Suction is necessary in case the patient aspirates because of difficulty swallowing. A. C. Oxygen and tissues may be helpful but will not clear the airway. D. A tongue blade is not necessary.

A mother of three young children who has a 3-year history of myasthenia gravis has had to stop helping in the childrens classrooms in the morning because of fatigue. What should the nurse say to help the patient best cope with the problem? a. You need to realize that you may not be able to do the things you used to do. b. Time your medication so that its action is peaking during the time you need the most energy. c. Getting plenty of sleep the night before you are scheduled to help will give you the stamina you need. d. If you wait to take your medication after you finish helping in the classroom, you may find that your energy level is better.

B The patient should be instructed to schedule activities at times when medication is at peak action so that muscle strength is increased. A. C. These statements may also be true but medication is needed to get through an activity. D. Taking the medication after the activity will help with strength after, not during, the activity.

The nurse is assisting with discharging a patient with myasthenia gravis after hospitalization for severe respiratory distress. Which patient statement indicates that the nurses discharge teaching has been effective? a. If I develop muscle cramping, I can take quinine as needed. b. I have to take my Prostigmin exactly as prescribed without skipping a dose. c. I know I should take my Prostigmin as needed, whenever I feel short of breath. d. I will take my anticholinergic medication to prevent developing respiratory distress again.

B With insufficient anticholinesterase medication, muscles can become weak. If respiratory muscles are affected, the patient can develop respiratory distress. C. Medication must be taken consistently to prevent weakness, not prn. A. D. Quinine and anticholinergic agents can exacerbate muscle weakness.

The nursing diagnosis Ineffective Airway Clearance has been identified for a patient with multiple sclerosis. Which interventions should the nurse include in this patients plan of care? (Select all that apply.) a. Measure intake and output b. Elevate the head of the bed c. Evaluate gag reflex every shift d. Monitor oxygen saturation twice a shift e. Encourage deep breathing and coughing every 2 hours

B, C, D, E Nursing interventions appropriate for the patient with Ineffective Airway Clearance include elevating the head of the bed, evaluating gag reflex every shift, monitoring oxygen saturation twice a shift, and encouraging deep breathing and coughing every 2 hours. A. Intake and output measurement would be more appropriate for the patient with a fluid volume imbalance.

The nurse is providing care to a patient with Guillain-Barr syndrome. Which laboratory result should the nurse evaluate first? a. Electrolytes b. Blood urea nitrogen (BUN) c. Arterial blood gases (ABGs) d. Hemoglobin (Hgb) and hematocrit (Hct)

C ABGs monitor respiratory status, which is essential in case the patients respiratory muscles become affected. B. Blood urea nitrogen (BUN) monitors kidney function. D. Hgb and Hct monitor blood loss or anemia. A. Electrolytes monitor fluid and electrolyte balance.

A patient with trigeminal neuralgia is admitted to the hospital for diagnostic testing and possible surgery. What intervention would be the most appropriate for this patient? a. Provide tissues for the patient to deal with drooling. b. Provide frequent mouth care with a firm toothbrush. c. Provide soft foods at body temperature at mealtimes. d. Provide a fan in the room to keep the room well ventilated.

C Activities such as talking, face washing, teeth brushing, shaving, and eating can cause pain in patients with trigeminal neuralgia. Soft foods at room temperature may be better tolerated than hot or cold foods. B. D. A fan or toothbrush can exacerbate pain. A. Patients with Bells palsy may drool but not patients with trigeminal neuralgia.

The nurse is providing eye care to a patient with Bells palsy. Which nursing action is most appropriate to help protect the affected eye? a. Keep the room lights dim at all times. b. Check for pupil response twice a day. c. Request an order for ointment and a patch. d. Apply a warm moist compress to the eye three times a day.

C Eyedrops and a patch can help keep the eye closed and protect the patients eye. D. A warm compress will not protect the eye, especially if it is only used three times a day. A. B. Dimming the lights and checking pupils will not protect the eye.

A patient who is prescribed neostigmine (Prostigmin) for newly diagnosed myasthenia gravis (MG) asks how the medication works. What should the nurse respond to the patient? a. It is a muscle relaxant that prevents the cramping in your muscles. b. It provides potassium to your muscles so that they will contract better. c. It makes more neurotransmitter available so that your muscles can contract. d. It reduces the inflammation in your nerves so that they transmit signals better.

C Medications used to treat MG include the anticholinesterase (ACh) drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon). These drugs improve symptoms of MG by destroying the acetylcholinesterase that breaks down ACh. A. B. This medication does not provide potassium or relax the muscles. D. Steroids reduce inflammation.

The nurse is reviewing nursing diagnoses identified for a patient with trigeminal neuralgia. Which nursing diagnosis should the nurse identify as a priority for this patient? a. Ineffective coping b. Self-care deficit: hygiene c. Pain related to inflammation of cranial nerve V d. Imbalanced nutrition: less than body requirements

C Pain takes priority. D. If pain is controlled, then the patient will be able to eat, and nutrition will not be a problem. A. Ineffective coping can be addressed after physiological problems. B. Hygiene is important but is not as high a priority as pain and nutrition.

A patient with multiple sclerosis has been prescribed baclofen (Lioresal) to relax muscles. What should be included in the nurses teaching about this drug? (Select all that apply.) a. Avoid crowds while on this medication. b. Take a calcium supplement while on this medication. c. Report any shortness of breath or other respiratory problems. d. Do not drive or operate machinery until the effects of the drug on you are known. e. Do not eat grapefruit, drink grapefruit juice, or consume other products containing grapefruit.

C, D, F Patients taking antispasmodics such as baclofen should avoid operating machinery and driving until effects are known. Measures should be provided to prevent constipation (except dantrolene). The patient should be monitored for respiratory depression. A. B. Calcium supplements are helpful with steroids, as is avoiding crowds due to infection risk. E. There is no restriction to grapefruit with this medication.

The nurse is assisting with the administration of a Tensilon test. What response to the test causes the nurse to suspect that the patient has myasthenia gravis? a. Dyspnea develops b. Muscle cramps develop c. Muscles become very weak. d. Ptosis is temporarily improved.

D A test for myasthenia gravis involves an intravenous injection of edrophonium (Tensilon, an anticholinesterase drug). If muscle strength improves dramatically (e.g., the patient can suddenly open the eyes wide), MG is diagnosed. A. B. C. Dyspnea, weakness, or cramping is not expected after Tensilon administration.

The nurse is caring for a patient with an exacerbation of multiple sclerosis (MS). What should the nurse include when teaching the patient about risk factors for exacerbation? a. Vegetarian diet b. Exposure to sun c. Sedentary lifestyle d. Urinary tract infection

D A variety of factors can trigger the onset of symptoms or aggravate the condition, including extreme heat and cold, fatigue, infection, and physical and emotional stress. A. B. C. Sun, sedentary lifestyle, and vegetarian diet are not known to exacerbate multiple sclerosis.

A patient with Bells palsy is experiencing symptoms. Which symptom should the nurse address first? a. Changes in taste b. Speech difficulty c. Drooping of one side of the face d. Inability to close the affected eye

D While all the problems will be disturbing to the patient, inability to close the eye could cause eye damage. A. B. C. The other problems do not usually cause permanent damage, and preventive measures will not be as helpful.