NURS309 - Neuro Quiz - 16
549. Which clinical findings does the nurse anticipate a client with an exacerbation of MS experience? (select all) 1. double vision 2. resting tremors 3. flaccid paralysis 4. scanning speech 5. mental retardation
1,4
557. a home care nurse is counseling with a client with ALS. what information should the nurse include in the discussion? (select all) 1. space activities throughout the day 2. engage in social interactions with large groups 3. request and opioid if leg pain becomes excessive 4. anticipate the use of alternate ways to communicate 5. use leg restraints to decrease the risk of physical injury
1,4
772. an ambulatory female client with relapsing-remitting MS is to receive every-other-day injections of interferon beta-1a (avonex). what adverse effects should the nurse explain may occur when taking this medication? (select all) 1. depressoin 2. constipation 3. flulike symptoms 4. increased heart rate 5. decreased perspiration
1234
140. a hospitalized client is receiving pyridostigmine (mestinon) for control of myasthenia gravis. in the middle of the night, the nurse finds the client weak and barely able to move. which additional clinical findings support the conclusion that these responses are related to pyridostigmine? (select all) 1. respiratory depression 2. distention of the bladder 3. decreased BP 4. fine tremor of the fingers 5. high-pitched gurgling bowel sounds
135
26. the LPN/LVN whom you are supervising comes to you and says "i gave the client with myasthenia gravis 90 mg of neostigmine (prostigmin) instead of the ordered 45 mg!" in which order should you perform the following actions? 1. assess the client's heart rate 2. complete a medication error report 3. ask the LPN/LVN to explain how the error occurred 4. notify the physician of the incorrect medication dose
1432
142. a client with MS is in remission. which diversional activity should the nurse encourage that BEST meets the client's needs while in remission? 1. hiking 2. swimming 3. computer classes 4. watching television
2
561. a nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. what should the nurse do FIRST? 1. administer oxygen 2. raise the HOB 3. perform tracheal suctioning 4. call the provider
2
551. a recently hospitalized client with MS is concerned about generalized weakness and fluctuating physical status. What is the PRIORITY nursing intervention for this client? 1. encourage bed rest 2. space activities throughout the day 3. teach the limitations imposed by the disease 4. have one of the client's relatives stay at the bedside
2 - encourages maximum functioning within limits of strength and fatigue
550. Which statement by a client with MS indicates to the nurse that the client needs further teaching? 1. "i use a straw to drink liquids" 2. "I will take a hot bath to help relax my muscles" 3. "i plan to use an incontinence pad when i go out" 4. "i may be having a rough time now, but i hope tomorrow will be better"
2 - increases symptoms and may result in burns because of decreased sensation
16. a client with MS tells the UAP after physical therapy that she is too tired to take a bath. what is the priority nursing diagnosis at this time? 1. fatigue related to disease state 2. activity intolerance due to generalized weakness 3. impaired physical mobility related to neuromuscular impairment 4. bathing self-care deficit related to fatigue and neuromuscular weakness
4
17. an LPN/LVN, under your supervision, is providing the nursing care for a client with GBS. what observation should you instruct the LPN/LVN to report immediately? 1. reports of numbness and tingling 2. facial weakness and difficulty speaking 3. rapid heart rate of 102 BPM 4. shallow respirations and decreased breath sounds
4
552. a client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? 1. localized seizures 2. skin desquamation 3. hyperactive reflexes 4. ascending weakness
4 - begins in lower extremities and moves upward
11. The nurse is monitoring a pt with GBS undergoing plasmapheresis. The pt reports dizziness and has a heart rate that has dropped to 48 BPM. The nurse notifies the primary care provider. Which order does the nurse anticipate? a. atropine IV push b. epinephrine IV push c. continue to monitor pt d. defibrillate the pt
a
49. a pt is receiving a cholinesterase (ChE) inhibitor drug for the treatment of MG. what is a nursing implication for the safe administration of this med? a. monitor for orthostatic hypotension b. take the pt's apical pulse prior to administration c. feed meals 45-60 min after administration d. drink at least 8 glasses of water each day
c
3. A pt with GBS is identified as having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this pt's nutritional status? (select all) a. checking the pt's skin turgor and urinary output b. giving the prescribed enteral feedings via feeding tube c. weighing the pt three times a week d. reviewing the pt's potassium and sodium levels e. monitoring weekly serum prealbumin level
ce
4. A pt with GBS has been intubated for respiratory failure. The nurse must suction the pt. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the pt for? a. thick secretions b. atrial fibrillation c. cyanosis d. bradycardia
d
25. Because the most common symptoms of MG are related to involvement of the levator palpebrae or extraocular muscles, which assessment technique does the nurse use? a. use a penlight and check for pupil size and response b. observe for protrusion of the eyeballs c. check accommodation by moving the finger toward the pt's nose d. face the pt and direct him or her to open and close the eyelids
d
18. The pt with GBS is immobile and shows evidence of malnutrition. What is the nurse's priority concern for this pt? a. respiratory failure b. inability to perform ADLs c. risk for pressure ulcers d. cardiac dysrhythmias
c
40. The pt is a woman in her early 30s who has recently been diagnosed with MS. The nurse has taught the pt's husband about the course of the illness and what problems might occur in the future. Which statement by her husband indicates the need for additional teaching? a. "she could fall because she may lose her balance and have poor coordination" b. "eventually she will not be able to drive because of vision problems" c. "she will probably have a decreased libido and diminished orgasm" d. "later on she could have intermittent short-term memory loss"
d
45. The 50-yr-old pt recently diagnosed with ALS is prescribed riluzole (Rilutek). When should the nurse teach the pt to take this drug? a. with a meal or snack b. on an empty stomach c. at bedtime d. one hour after taking an antacid
b
45. The nurse is performing teaching for the family of a pt with MG about fatigue and ADLs. Which statement by a family member indicates a need for additional teaching? a. "rest is critical because increased fatigue can precipitate a crisis" b. "we should do hygienic care for her to avoid undue frustration and fatigue" c. "activities should be done after we give her the medication" d. "the physical therapist will be able to recommend some energy-saving devices"
b
43. A pt with MG experienced a cholinergic crisis and is currently being maintained on a ventilator. The pt received several 1-mg doses of atropine. What does the nurse closely monitor this pt for? a. increasing muscle weakness b. increased salivation c. ventricular fibrillation d. development of mucus plugs
d
558. a client with myasthenia gravis experiences dysphagia. what is the PRIORITY risk associated with dysphagia that mush be considered when planning nursing care? 1. aspiration 2. dehydration 3. nutritional imbalance 4. impaired communication
1
564. a client with myasthenia gravis continues to become weaker despite treatment with neostigmine (prostigmin). what reason should the nurse identify for the health care provider's prescription for edrophonium (enlon)? 1. rule out cholinergic crisis 2. promote synergistic effect 3. overcome neostigmine resistance 4. confirm the diagnosis of myasthenia
1
18. the UAP reports to you, the RN, that a client with myasthenia gravis has an elevated temperature (102.2 F), an increased heart rate (120 BPM), and a rise in BP (158/92 mmHg) and was incontinent of urine and stool. what is your best first action at this time? 1. administer the acetaminophen suppository 2. notify the physician immediately 3. recheck vital signs in 1 hour 4. reschedule the client's physical therapy
2
554. A nurse is caring for a client with the diagnosis of guillain-barre syndrome. the nurse identifies that the client is having difficulty expectorating respiratory secretions. what should be the nurse's FIRST intervention? 1. auscultate for breath sounds 2. suction the client's oropharynx 3. administer oxygen via nasal cannula 4. place the client in the orthopneic position
2
563. a client with myasthenia gravis has been receiving neostigmine (prostigmin) and asks about its action. What information about its action should the nurse consider when formulating a response? 1. stimulates the cerebral cortex 2. blocks the action of cholinesterase 3. replaces deficient nuerotransmitters 4. accelerates transmission along neural sheaths
2
138. a client is admitted to the hospital with a diagnosis of myasthenia gravis. for which common early clinical finding should the nurse assess the client? 1. tearing 2. blurring 3. diplopia 4. nystagmus
3
553. what does the nurse understand that clients with myasthenia gravis, guillain-barre syndrome, and amyotrophic lateral sclerosis share in common? 1. progressive deterioration until death 2. deficiencies of essential neurotransmitters 3. increased risk for respiratory complications 4. involuntary twitching of small muscle groups
3
559. a client with myasthenia gravis asks the nurse why the disease has occurred. what pathology underlies the nurse's response? 1. a genetic defect in the production of acetylcholine 2. an inefficient use of the neurotransmitter acetylcholine 3. a decreased number of functioning acetylcholine receptor sites 4. an inhibition of the enzyme AChE, leaving the endplates folded
3
560. a client with myasthenia gravis asks the nurse, "what is going to happen to me and to my family?" what information about what the client can anticipate should be incorporated into the nurse's response? 1. high cure rate with proper treatment 2. slowly progressive course without remissions 3. chronic illness with exacerbations and remissions 4 poor prognosis, with death occurring in a few months
3
562. to what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1. narrowed airways 2. impaired immunity 3. ineffective coughing 4. viscosity of secretions
3
14. What is the priority expected outcome in a pt with GBS? a. maintain airway patency and gas exchange b. promote communication c. manage pain d. prevent complications of immobility
a
16. The pt with GBS describes a chronological progression of motor weakness that starrted in the legs and then spread to the arms and upper body. Which type of GBS do these symptoms indicate? a. ascending b. pure motor c. descending d. miller-fisher variant
a
9. Which interventions are appropriate for pain management in an older adult with GBS? (select all) a. IV opiates b. gabapentin (neurontin) c. tricyclic antidepressants d. massage e. music therapy
abde
44. The pt and family are referred to the nurse for education about amyotrophic lateral sclerosis (ALS). What information does the nurse include in the educational session? (select all) a. it is a progressive disease involving the motor system b. the cause of ALS is unknown c. memory loss will occur but it will be very gradual d. death typically will occur several decades after diagnosis e. there is no known cure for ALS
abe
44. The nurse is performing pt teaching about plasmapheresis. Which statement by the pt indicates understanding of the topic? a. "plasmapheresis causes immunosuppression, so i am at risk for infection" b. "i will have to be admitted to the hospital for this procedure" c. "two treatments are given over a 2-month period; then I must follow up on a monthly basis" d. "the goal of the treatment is to decrease symptoms, but it is not a cure"
d
50. A pt with a thymoma had surgery to relieve symptoms of MG. A single chest tube has been inserted into the pt's anterior mediastinum. The nurse notes that the pt is restless with diminished breath sounds and decreased chest wall expansion. What is the nurse's first priority action? a. reposition the pt and perform chest physiotherapy b. activate the rapid response team c. suction the pt and tell him to breathe deeply d. provide oxygen and elevate the HOB
d
35. The nurse is performing pt and family teaching about MG medication therapy. What important information does the nruse give during the teaching session? (select all) a. if a dose of cholinesterase is missed, a double dose is taken the next day b. antibiotics such as kanamycin synergize cholinesterase inhibitors c. medications must be taken on an empty stomach with a full glass of water d. administer with a small amount of food to decrease gastrointestinal upset e. if there is bulbar involvement, eat meals 45 min to 1 hour after taking the med f. drugs containing morphine or sedatives can increase muscle weakness
def
22. what is the cause of a cholinergic crisis? a. not enough anticholinesterase drugs b. too many anticholinesterase drugs c. some type of infection d. allergic reaction to anticholinersterase drugs
b
27. A pt with MG and the nurse are having a long discussion about plans for the future. After an extended conversation, what does the nurse anticipate will occur in this pt? a. speech will be slurred and difficult to understand b. voice may become weaker or exhibit a nasal twang c. voice quality will become harsh and strident d. voice will become toneless and affect will be flat
b
26. A pt with MG has "bulbar involvement". what is the nurse's priority assessment for this pt? a. presence of pain in the extremities b. loss of bowel and bladder function c. ability to chew and swallow d. quality and volume of the voice
c
17. The pt with GBS is in the plateau period. Which intervention is best for the nurse to delegate to the UAP? a. perform passive ROM every 2-4 hours b. turn the pt every 2 hours and assess for skin breakdown c. remove the antiembolism stockings every 24-48 hours and perform skin care d. make a communication board for the pt with a list of common requests
a
24. The nurse is reviewing the biographic data and history for a pt with MG. what does the nurse expect to see included in the pt's records? a. muscle weakness that increases with exertion or as the day wears on b. difficulty sleeping with early morning waking and restlessness c. confusion and disorientation in the late afternoon d. muscle pain and cramps that interfere with ADLs
a
6. The nurse is reviewing the cerebral spinal fluid (CSF) results for a pt with probable GBS. Which abnormal finding is common in GBS? a. increase in CSF protein level b. increase in CSF glucose level c. cloudy appearance of CSF d. elevation of lymphocyte count in CSF
a
41. The nurse is teaching a pt with MS and her family about her exercise program. Which points must the nurse include? (select all) a. ROM exercises are an important component b. rigorous activity should follow stretching exercises c. increased body temp can lead to increased fatigue d. progressive increased walking distances can lead to jogging e. stretching and strengthening exercises will be part of your program
ace
10. A pt with GBS is receiving IV immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. headache b. itching c. anaphylaxis d. fever
c
556. a nurse i scaring for a client in the home who has the diagnosis of amyotrophic lateral sclerosis (ALS). which position should the nurse recommend that the client assume after eating? 1. sims 2. sitting 3. side-lying 4. semi-fowler
4
760. the nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium (enlon) is used to establish the diagnosis. an increase in which factor will confirm the diagnosis? 1. symptoms 2. consciousness 3. blood pressure 4. muscle strength
4
555. what nursing intervention is anticipated for a client with guillain-barre syndrome? 1. providing a straw to stimulate the facial muscles 2. maintaining ventilator settings to support ventilation 3. encouraging aerobic exercises to avoid muscle atrophy 4. administering antibiotic medication to prevent pneumonia
2
28. A pt with MG reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is the pathophysiology of this pt's symptoms due to? a.limb weakness is more often proximal b. spinal nerves are affected c. large muscle atrophy is occurring d. demyelination of neurons is occurring
a
30. A pt is suspected of having MG and a tensilon test has been ordered. What does the nurse do to prepare the pt for the test? a. ensure that the pt has a patent IV access b. draw a blood sample and send it for baseline analysis c. keep the pt NPO after midnight d. have the pt void before the beginning of the test
a
38. A pt with MG has generalized weakness and fatigue and is limited in the ability to perform ADLs. Which nursing action is best to help this pt avoid excessive fatigue? a. schedule activities after med admin b. schedule activities during the lat afternoon or early morning c. during periods of maximal strength, provide assistnace for ambulation d. instruct UAP to assist with all ADLs and feedings
a
39. The nurse is reviewing med orders for a pt with MG. The pt is scheduled to receive pyridostigmine (mestinon) on a daily basis. What does the nurse expect regarding this drug? a. daily dosage change related to pt symptoms b. administration 30 min after antacids such as milk of magnesia c. immediate monitoring for decreased muscle strength d. gradual tapering and weaning off the drug
a
41. During shift report, the nurse learns that a pt with MG deteriorated toward the end of the shift and the physician was called. A tensilon test indicated the pt was having a myasthenic crisis. What is the priority problem for this pt? a. potential for inadequate oxygenation b. potential for decreased ability to perform ADLs c. potential for aspiration d. potential for increase in BP, pulse, and respirations
a
47. A pt with MG is having difficulty maintaining an adequate intake of food and fluid because of difficutly chewing and swallowing. Which task for this pt is best to delegate to the UAP? a. weigh the pt daily b. monitor calorie counts c. ask the pt about food preferences d. evaluate intake and output
a
19. The nurse is assessing a pt with myasthenia gravis (MG). Which manifestations can the nurse expect to observe? (select all) a. ptosis b. diplopia c. delayed puipllary responses to light d. incomplete eye closure e. decreased pupillary accomodation
abd
8. The pt with GBS is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? (select all) a. elevate HOB at least 45 degrees b. have pt assessed for dysphagia before administering oral fluids or medications c. teach the pt coughing or deep breathing exercises d. have suctioning equipment available at the bedside e. turn the pt from side to side at least every 2 hours
abd
52. The nurse is teaching the pt and family about factors that predispose the pt to episodes of exacerbation of MG. Which factors does the nurse mention? (select all) a. infection b. stress c. change in diet d. any physical exercise e. enemas f. strong cathartics
abef
46. A pt with MG is experiencing impaired communication related to weakness of the facial muscles. Which interventions are best in assisting the pt to communicate with the staff and family? (Select all) a. instruct the pt to speak slowly b. use short, simple sentences c. ask yes or no questions d. use hand signals e. have the pt use a picture, letter, or word board
ace
20. Which statements about MG are accurate? (select all) a. it is an acquired autoimmune disease b. it usually occurs in young adults c. it occurs slightly more in men than women d. it is often accompanied by weight gain and distal weakness e. it is associated with hyperplasia of the thymus gland f. it is characterized by remissions and exacerbations
acef
12. A pt has been newly diagnosed with GBS. the nurse is teaching the pt and family about the condition. Which statement by the family indicates a need for additional teaching? a. "he could recover in 4-6 months" b. "he'll never be able to walk again" c. "he will receive medication for pain" d. "it usually starts with the legs and moves upward"
b
15. The nurse is reviewing the admission and history notes for a pt admitted for GBS. which medical condition is most likely to be present before the onset of GBS? a. diabetes mellitus b. recent bacterial infection c. peripheral vascular disease d. addison's disease
b
21. What is the most important common electrodiagnostic test performed to detect MG? a. EMG b. repetitive nerve stimulation (RNS) c. tensilon challenge test d. EPS
b
32. What is considered a positive diagnostic finding of a tensilon test? a. after the cholinesterase inhibitor is administered, there are no observable changes in muscle strength or tone b. within 30-60 seconds after receiving the cholinesterase inhibitor, there is increased muscle tone that lasts 4-5 min c. within 30 min of receiving the cholinesterase inhibitor, there is improved muscle strength that lasts for several weeks d. after the cholinesterase inhibitor is first administered, the pt will experience muscle weakness and then return to baseline
b
34. The nurse is caring for a pt newly diagnosed with MG. The nurse is vigilant for complications related to both myasthenic crisis and cholinergic crisis. what is the priority nursing assessment for this pt? a. monitor cardiac rhythm and rate b. assess respiratory status and function c. monitor fatigue and activity levels d. perform neurologic checks every 2-4 hours
b
36. A pt with MG develops difficulty coughing. Auscultation of the lungs reveals coarse crackles throughout the lung fields. The nurse identifies the pt is unable to cough effectively enough to clear the airway of secretions. Which intervention is best for this pt? a. administer O2 2L per nasal cannula b. ask respiratory therapist to perform chest physiotherapy c. perform endotracheal suction d. perpare intubation equipment
b
37. A pt with MG is experiencing cholinergic crisis. Interventions include IV atropin 1 mg. what is the nurse's major respiratory concern when caring for this pt? a. increase heart rate b. difficulty with airway clearance c. copious secretions d. oxygen administration
b
39. A pt with MS is prescribed oral fingolimod (Gilenya). Which key point must the nurse teach the pt about the drug? a. "you must be carefully monitored for allergic or anaphylactic reaction because the drug tends to build up in the body" b. "we need to teach you how to monitor your pulse rate because this drug can cause a slow heart rate" c. "this drug will decrease the frequency of clinical relapses that you will have with MS" d. "it will improve your ability to walk but also puts you at increased risk for seizure activity"
b
42. A pt with MG has been referred to a surgeon for a procedure that may improve the pt's symptoms. Which procedure does the nurse anticipate will be recommended for this pt? a. percutaneous stereotactic rhizotomy b. thymectomy c. resecting severed nerve ends d. partial or complete severance of a nerve
b
42. The pt with MS has dysarthria (slurred speech). For which complication must the nurse monitor in this pt? a. dysmetria b. dysphagia c. ataxia d. vertigo
b
13. Which strategies should be incorporated in the plan of care to provide emotional support for a pt with GBS who has ascending paralysis? (select all) a. limit information provided to the pt and family b. encourage the pt to verbalize feelings c. teach the pt and famly about the condition d. explain all procedures and tests e. allow regularly scheduled rest periods f. assess previous coping skills
bcdef
51. Following a thymectomy for a pt with MG, the nurse notes that the pt is restless and experiencing chest pain and shortness of breath. What are the nurse's best actions at this time? (select all) a. instruct the pt to use incentive spirometry b. administer oxygen c. raise the HOB 45 degrees d. place the pt supine to encourage rest and sleep e. notify the rapid response team f. assist the pt to sit at the end of the bed
bce
1. The nurse is assessing a pt with a diagnosis of Guillain-Barre syndrome (GBS). Which S&S are consistent with GBS? (select all) a. bilateral sluggis pupil response b. sudden onset of weakness in the legs c. muscle atrophy of the legs d. change in LOC e. decrease deep tendon reflexes f. ataxia
bef
2. During shift report, the nurse hears that a pt with GBS has a decrease in vital capacity that is less than 2/3 of normal, and there is a progressive inability to clear and cough up secretions. The physician has been notified and is coming to evaluate the pt. What intervention is the nurse prepared to implement for this pt? a. frequent oral suctioning b. rigorous chest physiotherapy c. elective intubation d. elective tracheostomy
c
23. What test is used to differentiate a cholinergic crisis from a myasthenic crisis? a. EPS b. RNS c. tensilon testing d. CSF protein level
c
29. The nurse is planning activities for a pt with MG. which factor does the nurse consider to promote self-care, yet prevent excessive fatigue? a. time of day b. severity of symptoms c. medication times d. sleep schedule
c
31. The nurse is caring for a pt recently diagnosed and admitted with MG. during the morning assessment, the nurse notes some abnormal findings. Which symptom does the nurse report to the physician immediately? a. diarrhea b. fatigue c. inability to swallow d. difficulty opening eyelids
c
33. Although an adverse reaction to tensilon is considered rare, which medication should be readily available to give as an antidote in case a pt should experience complications? a. protamine sulfate b. narcan c. atropine sulfate d. regitine
c
40. The nurse is caring for a pt receiving cholinesterase inhibitor drugs for MG. Which symptoms does the nurse immediately report to the physician? a. increasing loss of motor function b. ineffective cough c. dyspnea and difficulty swallowing d. GI side effects
c
43. The pt with MS states she is bothered by diplopia (double vision). Which intervention does the nurse expect to implement? a. consult for corrective lenses b. teach the pt scanning techniques moving her head from side to side c. application of an eye patch alternating from eye to eye every few hours d. prophylactic bilateral patches to both eyes at night
c
7. An ambulatory pt has sought treatment of symptoms of GBS. IV immunoglobulin therapy has been prescribed. which precaution does the nurse expect with this therapy? a. it is given concurrently with plasmapheresis b. a shunt must be placed prior to beginning the therapy c. IV immunoglobulin is given slowly when started d. 3 or 4 treatments are given 1-2 days apart
c
48. Which interventions are appropriate to protect a pt with MG from corneal abrasions? (select all) a. instruct the pt to keep the eyes closed b. apply an eye patch to both eyes after breakfast c. administer artificial tears to keep corneas moist d. place a clean moist washcloth over the pt's eyes e. apply lubricant gel and shield to the eyes at bedtime
ce
5. A pt is admitted for a probable diagnosis of GBS, but needs additional diagnostic testing for confirmation. Which tests does the nurse anticipate will be ordered for this pt? (select all) a. electroencephalography (EEG) b. cerebral blood flow (CBF) c. electrophysiologic studies (EPS) d. electrocardiogram (ECG) e. electromyography (EMG)
ce