MS2- EXAM 3- Possible Test Blue Print Questions

A patient exhibits ptosis of both eyes, and the provider orders edrophonium (Tensilon). The nurse notes immediate improvement of the ptosis. The nurse understands that this patient most likely has which disorder?

ANS: Myasthenia gravis Rationale: Improvement of symptoms after administration of edrophonium is diagnostic for myasthenia gravis.

To prevent complications caused by a common problem of Huntington's disease, the nurse should

ANS: pad wheelchairs and beds Rationale: (Excessive movements and falling can cause injury in the client with Huntington's disease. Interventions include padding wheelchairs and beds, providing shin guards, and using gait belts for ambulation. Communication does become difficult and alternative forms of communication are appropriate before the client becomes completely demented, but this does not take priority over safety precautions. The client does not need an exercise regimen as the client is already hyperactive, and seizures do not occur.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)?

ANS: The client's respiratory status and muscle function are affected by both diseases.

The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in this patient?

ANS: Respiratory system and facial muscles Rationale: Myasthenia gravis causes fatigue and muscular weakness of the respiratory system, facial muscles and extremities. It does not directly affect the cardiovascular system, CNS, or GI systems.

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number.

ANS: 13 Rationale: The Glasgow Coma Scale (GCS) is used to measure the level of a client's consciousness and assigns a numerical score for each area of neurological status. The score for opening eyes on sound or speech is a 3. The score assigned for confused verbal responses is a 4. A score of 6 is assigned to the motor response of obeying commands. Therefore, the total score of the client is 13.

A client who had a brain attack (cerebrovascular accident, CVA) two weeks ago is having problems communicating. The nurse shows the client a picture of a baseball and asks the client to identify it and its characteristics. The client describes its color, size, and purpose but cannot identify it as a ball. How will the nurse document this finding in the client's medical record?

ANS: A A. Anomia

A patient who takes high-dose aspirin to treat rheumatoid arthritis has a serum salicylate level of 35 mg/dL. The nurse will perform which action? A. Assess the patient for tinnitus B. Monitor the patient for signs of Reye's syndrome C. Notify the provider of severe aspirin toxicity D. Request an order for an increased aspirin dose.

ANS: A Rationale: Mild toxicity occurs at levels above 30 mg/dL, so the nurse should assess for signs of toxicity, such as tinnitus. This level will not increase the risk for Reye's syndrome. Severe toxicity occurs at levels greater than 50 mg/dL. The dose should not be increased.

`A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. For what reason does the nurse recognize the importance of identifying restrictions of mobility or neuromuscular abnormalities? A. Shortening and eventual atrophy of the muscles will occur. B. Hypertrophy of the muscles eventually will result from disuse. C. Rigid extension can occur, making therapy painful and difficult. D. Decreased movement on the affected side predisposes the client to infection.

ANS: A Rationale: Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose to infection but to atrophy and contractures.

Which nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A. Activity intolerance B. Acute confusion C. Bowel incontinence D. Disturbed sleep pattern

ANS: A Rationale: The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.

Nursing activities for a client with ALS and family include helping them A. Decide on an acceptable level of care early in the course of the disease. B. Determine if they want to share the diagnosis to allow genetic testing C. Incorporate nonpharmacologic pain control techniques in the plan of care D. Plan for extensive rehabilitation after exacerbations

ANS: A Decide on an acceptable level of care early in the course of the disease Rationale: Disease management in ALS includes topics such as tube feedings and mechanical ventilation. Planning for an acceptable level of care should begin early in the disease, before a crisis occurs. Of course, decisions should be re-evaluated occasionally as the client's wishes may changes with their experiences with the disease. ALS is not a genetically-acquired disorder. Pain control is usually not an issue in the disease, and as the disease is relentlessly progressive (rather than characterized by remissions and exacerbations), extensive rehabilitation is not utilized.

A family member of a patient diagnosed with Huntington disease calls you at the clinic. She is requesting help from the Huntington's Disease Society of America. What kind of help can this patient and family receive from this organization? Select all that apply. A. Information about the disease B. Referrals C. Public education D. Individual assessments E. Appraisals of research studies

ANS: A, B, C A. Information about this disease B. Referrals C. Public education Rationale: The Huntington's Disease Society of America helps patients and families by providing information, referrals, family and public education, and support for research. It does not provide individual assessments or appraisals of individual research studies

The nurse is caring for a client who is diagnosed with fibromyalgia. Based on this diagnosis, which clinical manifestations might the nurse anticipate for this client? Select all that apply. A. Weakness B. Exhaustion C. Pain in the calves of the leg D. Nausea and vomiting E. Anxiety

ANS: A, B, E A. Weakness B. Exhaustion E. Anxiety Rationale: The client with fibromyalgia may experience weakness from fatigue; exhaustion from nonrestorative sleep, waking up too early, or poor sleep quality; and anxiety and other mood disorders. There is no evidence that pain in the calves, nausea, or vomiting are symptoms of fibromyalgia.

A client with myasthenia gravis is experiencing a myasthenic crisis. Which symptoms are associated with myasthenia gravis? Select all that apply. A. Weakness B. Fatigue C. Vomiting D. Sweating E. Drooling F. Tearing

ANS: A, B, E Rationale: Weakness and fatigue are prime symptoms of myasthenia gravis. The drooling is associated with the dysphagia.

The nurse is planning care for an immobilized client who has suffered a stroke. The client has right-sided hemiparesis. Which activity takes priority for this client? A. Assess the client lung sounds every 8 hours. B. Assist the client in performing range-of-motion (ROM) exercises every 1 to 2 hours. C. Allow the client to sit upright in the chair for as long as tolerated. D. Have the nursing assistant turn and reposition the client every 2 to 3 hours.

ANS: B B. Assist the client in performing ROM exercises every 1 to 2 hours.

The nurse provides teaching for a patient who will begin taking indomethacin (Inderal) to treat rheumatoid arthritis. Which statement by the patient indicates a need for further teaching? A. "I should limit sodium intake while taking this drug." B. "I should take indomethacin on an empty stomach." C. "I will need to check my blood pressure frequently." D. "I will take the medication twice daily."

ANS: B Rationale: Indomethacin is very irritating to the stomach and should be taken with food. It can cause sodium retention and elevated blood pressure, so patients should limit sodium intake. The medication is taken twice daily.

The client with longstanding MG is admitted to the acute care unit after having been diagnosed and treated for cholinergic crisis. Which of the following warning signs of cholinergic crisis will the nurse teach the family? A. Restlessness B. Vertigo C. Tachycardia D. Tachypnea

ANS: B Rationale: The usual cause of cholinergic crisis is overmedication while the cause of myasthenic crisis is undermedication. Manifestations of cholinergic crisis include GI manifestations, severe muscle weakness, vertigo, and resp distress

A client with MG began to experience a sudden worsening of her condition with difficulty breathing. The nurse explains that this complication of MG is usually initially treated with: A. Admission and administration of IV corticosteroids B. An increased dose of anticholinesterase drugs C. Bolus doses of atropine titrated to effect. D. Rest and increased sleep

ANS: B Rationale: With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug dose does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options are used to treat myasthenic

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should A. Attempt to institute bowel-training activities B. Provide the client with small, frequent feedings C. Obtain an order for intermittent catheterization. D. Orient the client to his or her surroundings frequently.

ANS: B Provide the client with small, frequent feedings Rationale: The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness.

A client who sustains a stroke has a loss of proprioception and fine touch. Which artery does the nurse suspect is damaged? A. Lateral cerebral B. Middle cerebral C. Anterior cerebral D. Posterior cerebral

ANS: C C. Anterior cerebral Rationale: Damage to the anterior cerebral artery can lead to a loss of proprioception and fine touch. Damage to the vertebral artery can cause dysphagia and dysarthria. Injury to the middle cerebral artery can cause motor and sensory deficits. Posterior cerebral artery damage can cause visual hallucinations and hemianopsia. There is no artery called lateral cerebral.

A client has had a carotid endarterectomy. To monitor for the complication of cranial nerve dysfunction, the nurse assesses the client for which finding? A. Labored breathing B. Edema of the neck C. Difficulty in swallowing D. Alteration in blood pressure

ANS: C C. Difficulty in swallowing

The nurse recognizes that a dose of an AChE inhibitor was given 1 hour late. The nurse anticipates that the client will exhibit which symptom as a result of the late dosage? A. Excessive salivation B. Difficulty breathing C. Muscle weakness D. Bradycardia

ANS: C C. Muscle weakness Rationale: All doses of AChE inhibitors should be administered on time, because late administration of the drug could result in muscle weakness.

A nurse is caring for a client with a history of rheumatoid arthritis who is receiving methotrexate. Which of the following should be included in client education? A. Methotrexate will decrease the risk of developing cancer B. Methotrexate can be administered during pregnancy C. The complete blood count (CBC) will be monitored D. Daily monitoring of blood glucose is recommended

ANS: C C. The complete blood count (CBC) will be monitored Rationale: Bone marrow suppression is a common side effect when using methotrexate for long term therapy in the treatment of rheumatoid arthritis. The client will have their complete blood count monitored periodically for evidence of anemia, neutropenia or thrombocytopenia.

A client takes prednisone (Deltasone), as prescribed for rheumatoid arthritis. During follow up visits, the nurse should assess the client for common adverse reactions to this drug, such as A. tetany and tremors B. anorexia and weight loss C. fluid retention and weight gain D. abdominal cramps and diarrhea

ANS: C Rationale: Common adverse reactions to prednisone and other steroids include sodium retention, fluid retention, and weight gain. Tetany and tremors are occasional adverse reactions to certain other drugs. Anorexia, abdominal cramps, and diarrhea are common adverse reactions to many drugs, but not to steroids.

Which physical assessment finding does the nurse expect to observe in a client with myasthenia gravis? A. Unstable mood B. Bowel and bladder incontinence C. Difficulty or inability to perform the 6 cardinal positions gaze D. Painful sensations

ANS: C Rationale: Early in the course of MG the muscles that control the eyes and eyelids are affected and this occurs in 90% of people with MG. Unstable mood, bowel and bladder incontinence, and painful sensations are all clinical manifestations of MS.

A client with myasthenia gravis is noted to be salivating, tearing, and sweating. The client complains of muscle weakness. What would the nurse anticipate administering? A. Pyridostigmine bromide B. Neostigmine C. Edrophonium D. Atropine sulfate

ANS: D D. Atropine sulfate Rationale: These are the major signs of cholinergic crisis; the client would be treated with the antidote, atropine sulfate.

The nurse is caring for a client with myasthenia gravis. What is essential for the nurse to teach this client regarding treatment? A. Frequent low-calorie snacks B. Strict monitoring of intake and output C. Use of sweeping gaze when walking D. Setting the alarm clock for medication times

ANS: D Rationale: Medication must be taken on time. Too early can cause complication of weakness and too late can cause extreme weakness to point of paralysis.

A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition? A. Chronic confusion B. Impaired urinary elimination C. Impaired verbal communication D. Bowel incontinence

ANS: C Impaired verbal communication Rationale: Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible. Intellectual function is marginally impaired in patients with late ALS. Usually, the anal and bladder sphincters are intact because the spinal nerves that control muscles of the rectum and urinary bladder are not affected.

Which clinical indicators does the nurse identify that suggest a client is experiencing urinary retention and overflow after a cerebrovascular accident (also known as a "brain attack")? Select all that apply. A. Edema B. Oliguria C. Frequent voidings D. Suprapubic distention E. Continual incontinence

ANS: C, D Rationale: With retention, the total amount of urine produced is unaffected. Atony permits the bladder to fill without being able to empty. As pressure builds within the bladder, the urge to void occurs, and just enough urine is eliminated to relieve the pressure and the urge to void. The cycle is repeated as pressure again builds. Thus small amounts are voided without emptying the bladder. As urine is retained and the bladder enlarges, it causes suprapubic distention. Edema is a sign of fluid volume excess, not urinary retention. Oliguria (urinary output less than 500 mL/day) is a sign of kidney failure. Continual incontinence does not occur with urinary retention.

A client with myasthenia gravis and his family are receiving instructions from the nurse. The nurse teaches the client that insufficient dosing of cholinesterase inhibitor may result in myasthenia crisis. The client is taught about which signs and symptoms of myasthenia crisis? A. Decreased muscle strength in the lower extremities B. Increased salivation and sweating C. Muscle weakness and increased salivation D. Muscle weakness, difficulty breathing and swallowing

ANS: D D. Muscle weakness, difficulty breathing and swallowing Rationale: These are the major signs of myasthenia gravis, which may be undertreated with insufficient dosing of the medication. Increased salivation is related to cholinergic crisis.

A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis?

ANS: Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness symptoms of cholinergic crisis caused by overmedication with cholinergic (anticholinesterase) drugs.

The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the health care provider will request which medication to aid in the diagnosis of MG?

ANS: Edrophonium chloride (Tensilon) and neostigmine bromide (Prostigmin) may be used for testing for MG. Tensilon is used most often because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors.

The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the health care provider if the client is taking which medication?

ANS: Procainamide (Pronestyl) should be avoided because it may increase the client's weakness

A client with myasthenia gravis is experiencing a cholinergic crisis. Which symptoms are associated with this condition? Select all that apply. A. Bradycardia B. Rash C. Vomiting D. Fever E. Drooling F. Weakness

ANS: A, C, E, F Rationale: Bradycardia, vomiting, drooling, and weakness can all occur with cholinergic crisis. *DOES VOMITING HAPPEN??*

The nurse assumes care of a patient who has myasthenia gravis and notes that a dose of neostigmine (Prostigmin) due 1 hour prior was not given. The nurse will anticipate the patient to exhibit which symptoms?

ANS: MUSCLE WEAKNESS Rationale: Neostigmine must be given on time to prevent myasthenic crisis, which is characterized by generalized, severe muscle weakness. Excessive salivation, muscle spasms and respiratory paralysis are characteristic of cholinergic crisis, caused by too much medication.

A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition? A. Inflamed peripheral nerves B. Loss of blood and blood volume C. Demyelination of peripheral nerves D. Blood pooling in the lower extremities

ANS: D D. Blood pooling in the lower extremities Rationale: Dilation of blood vessels causes dependent pooling when the client moves to an upright position, resulting in orthostatic (postural) hypotension. The client can limit feelings of lightheadedness and dizziness by moving gradually when changing positions. Inflammation of peripheral nerves is not the cause of the clinical manifestations. Loss of blood and blood volume causes hypovolemia, leading to shock. Demyelination of peripheral nerves leads to multiple sclerosis.

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? A. Monitoring vital signs B. Reassuring the client and family C. Assessing the level of consciousness D. Monitoring specific client manifestations of stroke

ANS: C C. Assessing the level of consciousness

A nurse is about to perform a wound irrigation on a client who had a left hemispheric stroke 1 year ago. Which assessment is most important for the nurse to perform before beginning the irrigation? A. Neurologic B. Wound C. Pain D. Skin

ANS: C C. Pain

A client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates a correct understanding of the nurse's instruction?

ANS: "I should call 911 if a sudden increase in weakness occurs." Rationale: A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis.

The nurse is caring for a patient who has myasthenia gravis (MG) and is receiving pyridostigmine bromide (Mestinon). The nurse notes ptosis of both eyelids and observes that the patient has difficulty swallowing. What action will the nurse perform next?

ANS: Contact the provider to request an order for edrophonium chloride (Tensilon). Rationale: Overdosing and underdosing of AChE inhibitors have similar symptoms: MUSCLE WEAKNESS, DYSPNEA, and DYSPHAGIA. Endrophonium may be used to diagnose MG or to distinguish between myasthenic crisis and cholinergic crisis since it is a very short-acting AChE inhibitor. When given, if the symptoms are alleviated, the cause is myasthenic crisis; if symptoms worsen, it is cholinergic crisis. Since patients can have similar symptoms, the nurse cannot report one or the other to the provider without more information.

A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?

ANS: Emotional and personality changes Rationale: Huntington disease causes profound changes to personality and behavior. It is a nonmalignant disease and stroke is not a central risk. The disease is not associated with pathologic bone fractures

The nurse is caring for a patient who has myasthenia gravis (MG) and takes pyridostigmine bromide (Mestinon) 60 mg every 4 hours. The patient's last dose was 45 minutes prior. The nurse notes severe muscle weakness, excessive salivation, fasciculations of facial muscles, and pupil constriction. The nurse will perform which action?

ANS: Obtain an order for ATROPINE SULFATE Rationale: Severe muscle weakness, excess salivation, fasciculations of facial muscles, and pupil constriction are the major signs of cholinergic crisis, caused by excess pyridostigmine. The antidote is atropine, so the nurse should obtain an order to give this. Ptosis is a sign of myasthenic crisis. IVIG is given to treat symptoms of MG and not used for cholinergic crisis. Giving extra pyridostigmine would increase the symptoms.

A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle? A. The patient is likely to have an increased appetite B. The patient is likely to require enzyme supplements C. The patient will likely require a clear liquid diet D. The patient will benefit from a low-protein diet

ANS: The patient is likely to have an increased appetite. Rationale: Due to the continuous involuntary movements, patients will have a ravenous appetite. Despite this ravenous appetite, patients usually become emaciated and exhausted. As the disease progresses, patients experience difficulty in swallowing and thin liquids should be avoided. Protein will not be limited with this disease. Enzyme supplements are not normally required

A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority?

ANS: The potential for ASPIRATION is the HIGHEST PRIORITY client problem because the client's ability to maintain airway patency is compromised.

The nurse explains that the pathology of Huntington's disease involves

ANS: an excess of the neurotransmitter dopamine Rationale: (The degeneration of the caudate nucleus leads to a reduction in several neurotransmitters, including gamma-aminobutyric acid, acetylcholine, substance P, and metenkephalin, and their synthetic enzymes. This change leaves relatively higher concentrations of the other neurotransmitters, dopamine and norepinephrine.

Health promotion activities the nurse could suggest to a community group for Huntington's disease include

ANS: genetic screening for high-risk individuals Rationale: Huntington's disease is inherited in an autosomal-dominant pattern. Genetic testing is available to families in which a member has Huntington's disease. The availability of the testing has created some ethical conflicts.

A 40-year-old woman is diagnosed with myasthenia gravis, and her provider recommends removal of her thymus gland. She asks the nurse why this would be helpful. The nurse will explain that the removal of the thymus gland may

ANS: reduce the autoimmune destruction of ACh receptor sites Rationale: Myastehnia gravis is an autoimmune disorder involving an antibody response against a subunit of the ACh receptor site. Since the thymus is involved in systemic immunity, it is thought that removing the thymus can inhibit this process. It does not increase binding of ACh molecules to receptors or increase the amount of ACh or reduce the number of ACh receptor sites.

A patient reports weakness of the extremities and diplopia. The nurse knows that these symptoms are characteristic of which condition? A. Cerebral palsy (CP) B. Multiple sclerosis (MS) C. Myasthenia gravis (MG) D. Parkinson's disease (PD)

ANS: B. Multiple sclerosis (MS) Rationale: Diplopia and weakness of the extremities are two symptoms of MS. CP is characterized by muscle spasticity. MG involves generalized weakness, especially of facial muscles and respiratory muscles. PD manifests as tremors and difficulty moving and walking.

The charge nurse observes a nurse administer undiluted intravenous pyridostigmine bromide (Mestinon) at a rate of 0.8 mg/min. The charge nurse will stop the infusion and perform which action? A. Administer atropine sulfate to prevent cholinergic crisis B. Monitor the patient closely for respiratory distress C. Suggest that the nurse dilute the medication with colloidal fluids D. Tell the nurse to slow the rate of infusion of the pyridostigmine

ANS: D. Tell the nurse to slow the rate of infusion of the pyridostigmine. Rationale: When given, IV pyridostigmine should be administered undiluted at a rate of 0.5 mg/min and should not be added to IV fluids. It is not necessary to administer atropine, since the patient is not symptomatic of cholinergic crisis.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? A. "MG is an autoimmune problem in which nerves do not cause muscles to contract." B. "MG is an inherited destruction of peripheral nerve endings and junctions." C. "MG consistst of trauma-induced paralysis of specific cranial nerves." D. "MG is a viral infection of the dorsal root of sensory nerve fibers."

ANS: A A. "MG is an autoimmune problem in which nerves do not cause muscles to contract." Rationale: MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

The nurse was assessing an elderly client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. What could be the approximate stroke volume? A. 70 mL B. 60 mL C. 50 mL D. 40 mL

ANS: A A. 70 mL Rationale: Cardiac output is obtained by multiplying the heart volume and stroke volume. Therefore to obtain the stroke volume, the cardiac output should be divided by pulse rate. Dividing 5950 by 85 yields a stroke volume of 70 mL.

A client is experiencing sudden-onset severe pain in the left lower quadrant of the abdomen that is rated as a 10 on a pain scale of 0-10. The client is also experiencing nausea, vomiting, and restlessness. Based on this data, the nurse concludes that the client is experiencing which phenomenon? A. Acute pain B. Chronic pain C. End-of-life pain D. Fibromyalgia pain

ANS: A A. Acute pain Rationale: Duration establishes the difference between acute and chronic pain. Acute pain is defined as pain that lasts only through the expected recovery period, which is usually 30 days to 6 months. Acute pain typically has a sudden onset related to injury, surgery, or illness. Chronic pain outlasts the illness and extends beyond the recovery period. End-of-life and fibromyalgia would most likely involve chronic pain.

A client is taking long-term cotricosteroids for myasthenia gravis. What teaching is most important? A. Avoid large crowds and people who are ill. B. Check blood sugars four times a day. C. Use two forms of contraception. D. Wear properly fitting socks and shoes

ANS: A A. Avoid large crowds and people who are ill Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.

The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke. What is the most effective professional management strategy for the RN to improve the safety and quality of client care? A. Delegation B. Leadership C. Supervision D. Assignment

ANS: A A. Delegation Rationale: Delegation is the most effective professional management strategy to implement in clinical practice to improve the safety and quality of client care by the registered nurse. Leadership is the action of leading a group, which is not suitable in this situation. Supervision is the active process of directing, guiding, and influencing the outcomes. Assignment is the transfer of both accountability and the responsibility from one person to another.

A client has carotid atherosclerotic plaques, and a right carotid endarterectomy is performed. Two hours after surgery the client demonstrates progressive hypotension. Which action should the nurse take? A. Notify the healthcare provider B. Increase the intravenous (IV) flow rate C. Raise the head of the bed D. Place the client in the Trendelenburg position

ANS: A A. Notify the healthcare provider Rationale: The healthcare provider must evaluate the cause of the hypotension. Increasing the IV flow rate Is a dependent function that requires a healthcare provider's prescription. Raising the head of the bed will further decrease blood flow to the brain. The Trendelenburg position is contraindicated because it will increase pressure in the carotid arteries.

What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? A. Places objects within the visual field. B. Teach passive range-of-motion exercises. C. Instill artificial teardrops into the affected eye. D. Reduce time client is positioned on the left side.

ANS: A A. Place objects within the visual field. Rationale: A stroke in the left hemisphere will lead to a loss of the right visual field of each eye; objects should be placed within the clients view. Passive range-of-motion exercises, artificial teardrops, and reducing time client is positioned on the left side are not related to hemianopsia.

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7? A. Preparing for intubation B. Observing for chest wall trauma C. Covering the client with a blanket D. Applying direct pressure to the client's wound

ANS: A A. Preparing for intubation Rationale: If the Glasgow Coma Scale (GCS) is 8 or less, the priority action by the nurse is to prepare for endotracheal intubation because the client is at risk for airway compromise. Observing for chest wall trauma, covering the client with a blanket, and applying direct pressure to a bleeding wound are all appropriate actions but not the priority.

A client with MG develops a sudden increase in weakness, accompanied by an increase in heart rate from 76-100 bpm and an increase in blood pressure from 122/72 to 152/82 mmHg. Which conclusion will the nurse reach from these findings? A. The patient is experiencing myasthenic crisis B. The patient has orthostatic hypotension C. The patient is overweight D. The patient drank too much alcohol

ANS: A Rationale: Myasthenic crisis is characterized by an increase in muscle weakness and a rise in heart rate and blood pressure. With orthostatic hypotension the BP would decrease by 10 or 20 mmHg upon standing. Although being overweight and drinking alcohol can cause a higher blood pressure it is not the reason for the sudden increase

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone (Deltasone). When caring for this client, the nurse should monitor for which e drug reactions? A. Increased weight, hypertension, and insomnia B. Vaginal bleeding, jaundice, and inflammation C. Stupor, breast lumps, and pain D. Dyspnea, numbness, and headache

ANS: A Rationale: Prednisone can cause a wide range of adverse reactions, including increased weight caused by fluid retention, hypertension, insomnia, ecchymoses, suppressed inflammation, behavioral changes, and myopathy. However, it doesn't produce the signs and symptoms listed in options B, C, and D.

A client is admitted with myasthenia gravis (MG). During the admission assessment, the nurse identifies that the client's upper eyelids are drooping. Which term should the nurse document to describe this assessment finding? A. Ptosis B. Myopia C. Keratitis D. Astigmatism

ANS: A Rationale: Ptosis (A), a hallmark finding in MG, describes drooping of the eyelids associated with neuromuscular disorders, such as MG, a chronic disease from an autoimmune response that destroys acetylcholine receptors and affects the neuromuscular junction. (B, C, and D) are diagnostic and not descriptive terms used in documenting assessment findings. Myopia (B) is nearsightedness. Keratitis (C) is inflammation of the cornea. Astigmatism (D) is a refractive condition. From HESI comprehensive Exam 3

A client with myasthenia gravis has been prescribed to take pyridostigmine (Mestinon). What health teaching will the nurse include related to this drug? Select all that apply. A. "Watch for signs and symptoms of myasthenic crisis." B. "Take the drug about an hour before eating a meal." C. "Take the same dose of medication every day." D. "Take the drug with food to prevent nausea." E. "Do not take sedatives or sleeping pills while on this drug."

ANS: A, B, C, E Rationale: The client and family should watch for an exacerbation of myasthenic symptoms caused by underdosing of anticholinesterase drugs. The client should eat meals 45 minutes to 1 hour after taking pyridostigmine to avoid aspiration; this is especially important if the client has bulbar involvement. The client should be told that he or she should take the same dose of medication daily and on time to maintain blood levels and improve muscle strength; changing doses daily will interfere with interpretation of blood levels and adjustment of the doses. The client should not take drugs containing magnesium, morphine (or its derivatives curare, quinine, quinidine, procainamide), or hypnotics or sedatives because they may increase weakness. The client should not take pyridostigmine with food.

A client with myasthenia gravis is prescribed pyridostigmine (Mesinon). What should the nurse plan regarding this medication? Select all that apply. A. "Do not eat a full meal for 45 minutes after taking the drug." B. "Seek immediate care if you develop trouble swallowing." C. "Take this drug on an empty stomach for best absorption." D. "The dose may change frequently depending on symptoms." E. "Your urine may turn a reddish-orange color while on this drug."

ANS: A, B, D A. "Do not eat a full meal for 45 minutes after taking the drug." B. "Seek immediate care if you develop trouble swallowing." D. "The dose may change frequently depending on symptoms." Rationale: Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine will not turn reddish-orange while on this drug.

A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. Which areas of paralysis should the nurse find upon assessment? Select all that apply. A. Left lef B. Left arm C. Right leg D. Right arm E. Left side of face

ANS: A, B, E Rationale: Because nerves decussate (cross over), paralysis occurs on the side of the body opposite to the area of cerebral involvement. The right leg and right arm will not be affected because the insult is to the right cerebral cortex and nerve fibers decussate before reaching the periphery. The face is innervated by the seventh cranial nerve, which comes in pairs (right and left) that do not decussate; therefore, because injury is to the right cerebral cortex, the left seventh cranial nerve is damaged. This leads to paralysis of the left side of the face.

When caring for a client with myasthenia gravis, which of these nursing activities may be safely delegated to a nursing assistant? Select all that apply. A. Feeding dinner to the client B. Teaching the family about drug therapy C. Assisting with client communication D. Consulting with the physical therapist E. Assisting with ambulation F. Recording food and fluid intake

ANS: A, C, E, F Rationale: The nursing assistant may assist with client feeding, communication, ambulation, and recording food and fluid intake. Any difficulties that arise when assisting the client with these activities should be reported immediately to the registered nurse. The nurse is responsible for education related to drug therapy, indications for use, dosages, and adverse reactions, as well as interdisciplinary collaboration. However, the nursing assistant may assist the physical therapist at the bedside or communicate with him or her.

The nurse cautions clients with ALS and their families to be aware that: (Select all that apply). A. Activities should be spaced throughout the day. B. Clients experience incontinence, an early cause of falling. C. Cognition will usually decline late in the disease. D. Muscle weakness may cause a risk for injury.

ANS: A, D Rationale: Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder.

The nurse is providing care for a client who had an endarterectomy 1 month ago. The nurse explains the reason that clopidogrel is being prescribed. The nurse concludes that the teaching is understood when the client makes which statement? A. "Clopidogrel will limit inflammation around my incision." B. "Taking this drug will help prevent further clogging of my arteries." C. "The medication will lower the slight fever I have had since surgery." D. I will take this drug to reduce the discomfort I feel at the surgical incision."

ANS: B B. "Taking this drug will help prevent further clogging of my arteries."

The nurse is assessing four clients with ischemic stroke. Which client requires a medium priority of care according to the National Institutes of Health Stroke Scale (NIHSS) score? A. A client with visual score of 3 B. A client with facial palsy score of 1 C. A client with a level of consciousness score of 0 D. A client with motor and drift of each extremity score of 4

ANS: B B. A client with facial palsy score of 1 Rationale: A client with ischemic stroke and a facial palsy score of 1 has minor paralysis is a medium priority. A client with a visual score of 3 who may be blind or have bilateral hemianopsia is a high priority. A client with a consciousness score of 0 is stable and will be least priority. A client with a motor and drift score of 4 indicates no movement and requires an emergent priority.

A client with atrial fibrillation has a stroke, and vascular dementia (multiinfarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? A. Memory impairment B. Abrupt onset of symptoms C. Difficulty making decisions D. Inability to use words to communicate

ANS: B B. Abrupt onset of symptoms

A nurse uses a dull object to stroke the lateral side of the underside of a client's left foot and moves upward to the great toe. What reflex is the nurse testing? A. Moro B. Babinski C. Stepping D. Cremasteric

ANS: B B. Babinksi Rationale: This is the description of how to elicit the Babinski reflex. If it is present in adults it may Indicate a lesion of the pyramidal tract. The Babinski reflex is expected in newborns and disappears after one year. The Moro (startle) reflex is expected in newborns It disappears between the third and fourth months; if present after four months, neurologic disease is suspected. The stepping reflex is expected in newborns. It disappears at about 3 to 4 weeks after birth and is replaced by more deliberate action. The cremasteric is a superficial reflex that tests lumbar segments 1 and 2. Stimulation of this reflex is useful in initiating reflex emptying of the spastic bladder after a spinal cord disruption above the second, third, or fourth sacral segment.

The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? A. Glasgow Coma score of 10 B. Body temperature of 81.2 degrees F C. Oxygen saturation of 90 % D. Presence of carotid pulse with blood pressure of 80 mm Hg

ANS: B B. Body temperature of 81.2 degrees F Rationale: Severe hypothermia such as body temperature of 81.2 degrees F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90% indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mmHg is acceptable.

A client with myasthenia gravis demonstrates diplopia, ptosis, and dysphagia. The client is ordered to receive pyridostigmine bromide (Mestinon). What would indicate a positive outcome? A. Increase in the ability to sleep B. Decrease in muscle weakness C. Increase in hemiparesis D. Decreased metabolic rate

ANS: B B. Decrease in muscle weakness Rationale: A decrease in weakness would indicate a positive response.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it where?

ANS: B B. On the right side Rationale: The cane should be used on the stronger (unaffected) side of the body to add strength, decrease dependence on the weaker (affected) side, and aid in balance during ambulation. Correct use of a cane does not involve alternating sides, using the cane on the affected (weaker) side, or using the side of the client's choice.

A patient has an order for the monoclonal antibody adalimumab (Humira). The nurse notes that the patient does not have a history of cancer. What is another possible reason for administering this drug? A. Severe anemia B. Rheumatoid arthritis C. Thrombocytopenia D. Osteoporosis

ANS: B B. Rheumatoid arthritis Rationale: Monoclonal antibodies are used for the treatment of cancer, rheumatoid arthritis and other inflammatory diseases, multiple sclerosis, and organ transplantation.

Abatacept (Orencia) is prescribed for a patient with severe rheumatoid arthritis. The nurse checks the patient's medical history, knowing that this medication would need to be used cautiously if which condition is present? A. Coronary artery disease B. Chronic obstructive pulmonary disease C. Diabetes mellitus D. Hypertension

ANS: B Rationale: Abatacept must be used cautiously in patients with recurrent infections or chronic obstructive pulmonary disease. The other options are incorrect.

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? A. Client who reports jaw pain when eating B. Client with a red, hot, swollen right wrist C. Client who has a puffy-looking area behind the knee D. Client with a worse joint deformity since the last visit

ANS: B Rationale: All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

A patient who has been diagnosed with Sjögren's syndrome will be given cevimeline for the treatment of xerostomia. The nurse will monitor for what therapeutic effect? A.. Reduction of salivation B. Stimulation of salivation C. Reduction of gastrointestinal peristalsis D. Improvement of fine-motor control

ANS: B Rationale: Cevimeline is a direct-acting cholinergic drug that is used to stimulate salivation in patients who have xerostomia (dry mouth), one of the manifestations of Sjögren's syndrome. The other options are incorrect.

The nurse is caring for a patient who has rheumatoid arthritis and who is receiving infliximab (Remicade) IV every 8 weeks. Which laboratory test will the nurse anticipate that this patient will need? A. Calcium level B. Complete blood count C. Electrolytes D. Potassium

ANS: B Rationale: Infliximab is an immunomodulator and can cause agranulocytosis, so patients should have regular CBC evaluation.

(NOT SURE) ****** When caring for a client with myasthenia gravis, the nurse should assess the client for which of the following manifestations of cholinergic crisis? Select all that apply. A. Decreased secretions and saliva B. Ptosis C. Abdominal cramps D. Increased heart rate E. Fasciculation F. Respiratory rate of 6 and irregular

ANS: B, C, E, F

A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? Select all that apply. A. Urinalysis B. Erythrocyte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. WBC count

ANS: B, D, E Rationale: B- ESR is a laboratory test used to diagnose RA. This laboratory test will show an ELEVATED result in clients who have RA. D- ANA titer is a laboratory test used to diagnose RA. This laboratory test will show a POSITIVE result in clients who have RA. E- WBC count is a laboratory test used to diagnose RA. This laboratory test will show a DECREASED result in clients who have RA. A urinalysis is not a laboratory test used to diagnose RA. This test can be used for detecting kidney failure. A BUN is not a laboratory test used to diagnose RA. This test can be used for detecting kidney failure.

The nurse has instructed the client with myasthenia gravis about ways to manage his or her own health at home. The nurse determines that the client needs further teaching if the client makes which statement? A. "Here's the Medic-Alert bracelet I obtained." B. "I should take my medications an hour before mealtime." C. "Resting in a sauna will be a relaxing form of activity." D." I've made arrangements to get a portable resuscitation bag and home suction equipment."

ANS: C C. "Resting in a sauna will be a relaxing form of activity."

A nurse is teaching a client with hemiparesis how to ambulate with a cane. What should the nurse instruct the client to do? A. Shorten the stride of the unaffected extremity B. Lean the body toward the cane when ambulating. C. Advance the cane simultaneously with the affected extremity. D. Hold the cane in the hand on the side of the affected lower extremity.

ANS: C C. Advance the cane simultaneously with the affected extremity. Rationale: The cane is held on the unaffected side and is advanced at the same time as the affected extremity; this increases the base of support and provides stability. Shortening the stride of the unaffected extremity will produce an awkward gait and instability; regular ambulation should be approximated. Leaning the body will change the center of gravity and cause instability. Holding the cane in the hand on the side of the affected lower extremity does not provide for a wide base of support or stability.

As a part of a teaching session, a client with myasthenia gravis and her family are receiving instructions from the nurse. The nurse teaches the client that overdosing of cholinesterase inhibitor may result in cholinergic crisis. The client is taught about which signs and symptoms of cholinergic crisis? A. Decreased muscle strength and decreased salivation B. Increased salivation and sweating C. Muscle weakness and increased salivation D. Muscle spasticity and decreased salivation

ANS: C C. Muscle weakness and increased salivation Rationale: These are the major signs of cholinergic crisis.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? A. Adminstering anxiolytics B. Having a ventilatior nearby C. Obtaining atropine sulfate D. Sedating the client.

ANS: C C. Obtaining atropine sulfate Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include? A. Approaching the client from the left side B. Keeping the client's head turned to the right C. Teaching the client to use head movements to scan the left field of vision D. Arranging the furniture in the client's room so that the door is in the right visual field

ANS: C C. Teaching the client to use head movements to scan the left field of vision.

A nurse is aware that when treating a client with cholinesterase inhibitors, it is imperative to have the antidote at the bedside. The nurse anticipates that the client will be ordered A. epinephrine B. norepinephrine C. atropine D. edrophonium chloride (Tensilon)

ANS: C C. atropine Atropine is the drug choice for cholinergic crisis.

A patient is receiving hydroxychloroquine therapy but tells the nurse that she has never traveled out of her city. The nurse knows that a possible reason for this drug therapy is which condition? A. Lyme disease B. Toxoplasmosis C. Systemic lupus erythematosus D. Intestinal tapeworms

ANS: C Rationale: Hydroxychloroquine, which is used for malaria, also possesses anti-inflammatory actions and has been used to treat rheumatoid arthritis and systemic lupus erythematosus. The other options are incorrect.

A cholinergic drug is prescribed for a patient with a new diagnosis of myasthenia gravis, and the nurse provides instructions to the patient about the medication. What is important to include in the teaching? A. Take the medication with meals to avoid gastrointestinal distress. B. Give daytime doses close together for maximal therapeutic effect. C. Take the medication 30 minutes before eating to improve swallowing and chewing. D. Take the medication only if difficulty swallowing occurs during a meal.

ANS: C Rationale: Taking the medication 30 minutes before meals allows time for the onset of action and therapeutic effects during the meal. The doses should be spaced evenly apart to optimize the effects of the medication. The other options are incorrect.

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply. A. Make the referral after the client is discharged. B. Select a suitable rehabilitation center for the client. C. Explain the need for referral to the client and family. D. Provide the referral with adequate client information E. Determine what the referral recommends for client care.

ANS: C, D, E Rationale: Clients are discharged from health care facilities as soon as their conditions allow. Therefore they often need referrals for continuing care from another provider. It is important for the nurse to explain the need for the referral to the client and family. The nurse must coordinate with the referral and provide all necessary client information to prevent duplication of effort or exclusion of important information. The nurse must determine the referral recommendations for client care and include it in the treatment plan. Discharge planning starts as soon as the client is admitted to the health care facility. Therefor the nurse must plan for the referral as soon as possible, not after the client is discharged. The nurse should involve the client and family in the referral process. The client and family should be allowed to select a suitable rehabilitation center.

A 75-year-old woman has been given a non-steroidal anti-infammatory drug (an NSAID for the treatment of rheumatoid arthritis). The nurse is reviewing the patient's medication history and notes that which types of medications could have an interaction with the NSAID? Select all that apply. A. Antibiotics B. Decongestants C. Anticoagulants D. Beta Blockers E. Diuretics F. Corticosteroids

ANS: C, E, F C. Anticoagulants E. Diuretics F. Corticosteroids Rationale: Anticoagulants taken with NSAIDs may cause increased bleeding tendencies because of platelet inhibition and hypoprothrombinemia. NSAIDs taken with diuretics may cause reduced hypotensive and diuretic effects. NSAIDs taken with corticosteroids may cause increased ulcerogenic effects. The other options are incorrect.

Initially after a brain attack (stroke, cerebrovascular accident), a client's pupils are equal and reactive to light. Four hours later the nurse identifies that one pupil reacts more slowly than the other. The client's systolic blood pressure is beginning to increase. On which condition should the nurse be prepared to focus care? A. Spinal shock B. Brain herniation C. Hypovolemic shock D. Increased intracranial pressure

ANS: D D. Increased intracranial pressure Rationale: Increased intracranial pressure is manifested by a sluggish pupillary reaction and elevation of the systolic blood pressure. Spinal chock is manifested by a decreased systolic blood pressure with no pupillary changes. Brain herniation is manifested by dilated pupils and severe posturing. Hypovolemic shock is indicated by a decrease in systolic pressure and tachycardia, with no changes in pupillary reaction.

Initially after a stoke, a client's pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic blood pressure is beginning to rise. What complication should the nurse consider that the client is developing? A. spinal shock B. Hypovolemic chock C. Transtentorial herniation D. Increasing intracranial pressure

ANS: D D. Increasing intracranial pressure Rationale: Increased intracranial pressure compresses vital brain tissue; this is manifested by a sluggish pupillary response and an increased systolic blood pressure. Spinal shock is manifested by decreased systolic blood pressure, with no pupillary changes. Hypovolemic shock is indicated by decreased systolic pressure and tachycardia, with no changes in pupillary reaction. Transtentorial herniation is manifested by dilated pupils and severe posturing.

A patient experiences severe muscle weakness, and the provider orders endrophonium bromide (Tensilon). The patient begins to show improved muscle strength within a few minutes after administration of this drug. The nurse anticipates the provider will order which drug? A. Atropine sulfate B. Edrophonium bromide (Tensilon) C. Intravenous immune globulin (IVIG) D. Pyridostigmine HCl (Mestinon)

ANS: D D. Pyridostigmine HCl (Mestinon) Rationale: In this case, edrophonium is used to diagnose myasthenia gravis. Since symptoms improved with the AChE inhibitor, the patient will benefit from a longer-acting AChE inhibitor such as pyridostigmine. Atropine is given for AChE inhibitor overdose. Edrophonium is very short-acting, so it will not be used for treatment. IVIG is used when other AChE inhibitors fail.

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? A. Ability to chew and swallow without aspiration B. Eating 75% of meals and between-meal snacks C. Intake greater than output 3 days in a row D. Weight gain of 3 lbs in 1 month

ANS: D D. Weight gain of 3 lbs in one month Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.

You are the nurse caring for a patient diagnosed with Huntington's disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patient's plan of care? A. Firmly redirect the patient's head when feeding B. Administer phenothiazines after each meal as ordered. C. Encourage the patient to keep his or her feeding area clean. D. Apply, deep, gentle pressure around the patient's mouth to aid swallowing.

ANS: D Apply deep, gentle pressure around the patient's mouth to aid swallowing. Rationale: Nursing interventions for a patient who has inadequate nutritional intake should include the following: Apply deep gentle pressure around the patient's mouth to assist with swallowing, and administer phenothiazines prior to the patient's meal as ordered. The nurse should dis-regard the mess of the feeding area and treat the person with dignity. Stiffness and turning away by the patient during feeding are uncontrollable choreiform movements and should not be interrupted