Peripheral Nervous System Problems NCLEX

The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching? a. I will change positions slowly. b. I will avoid wearing cotton socks. c. I will use an electric razor. d. I will use a heating pad on my feet.

A ~ Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad. The disorder does not cause bleeding; therefore the client can use any type of razor.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain her feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that she will become malnourished in time.

A ~ Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.

The nurse reviews laboratory data for a client who has Guillain-Barr syndrome (GBS). Which result does the nurse correlate with this disease process? a. Increased cerebrospinal fluid (CSF) protein level b. Decreased serum protein electrophoresis results c. Increased antinuclear antibodies d. Decreased immune globulin G (IgG) levels

A ~ A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS. The other results are not associated with GBS.

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client? a. Suction the client to remove secretions. b. Turn and reposition the client every 2 hours. c. Measure urinary output every 30 minutes. d. Administer prescribed anticholinergic drugs as needed.

A ~ Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important. The other interventions do not relate to the administration of atropine.

A client is taking long-term corticosteroids 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.

A ~ 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.

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (SATA) 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.

A, B, D ~ 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 afterward. The client's urine will not turn reddish-orange while on this drug.

The nurse caring for a client with Guillain-Barr syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (SATA) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

A, B, E ~ Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered? a. Babinski reflex test b. Tensilon test c. Cholinesterase challenge test d. Caloric reflex test

B ~ The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis. A Babinski reflex and caloric reflex test would not be appropriate for this client.

The nurse assesses a client with Guillain-Barr syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure? a. Tachycardia b. Hypovolemia c. Hyperkalemia d. Hemorrhage

B ~ The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated. The other manifestations are not complications of plasmapheresis.

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client? a. Administer a therapeutic massage. b. Collaborate with the physical therapist. c. Perform passive range-of-motion exercises. d. Reposition the client every 2 hours.

B ~ The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. Therapeutic massage, passive range of motion, and repositioning will not reduce muscle weakness.

The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively? a. Evaluate extremity mobility. b. Assess the skin surrounding the cast. c. Test distal extremities for sensation. d. Auscultate bowel sounds.

B ~ The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and color. If the cast is too tight, the nurse notifies the provider immediately. The other assessments should be completed after a circulatory assessment.

An older adult client is hospitalized with Guillain-Barr syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (SATA) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

B, C, E ~ Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA) a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily

B, D ~ Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.

A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

C ~ Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

C ~ Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

D ~ Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best? a. Advise the client to restrict fluids. b. Assess the client for signs of infection. c. Have the client add table salt to food. d. Instruct the client on a magnesium supplement.

D ~ Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed.

A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the clients family members or caregiver? a. Technique for therapeutic massage to the lower extremities b. Administration of morphine sulfate via an IV pump c. Instructions for preparing thin, pured foods d. Cardiopulmonary resuscitation (CPR)

D ~ Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home. The other interventions are not a priority.

A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (SATA) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)

A, C, D, E ~ Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.

An older client is hospitalized with Guillain-Barr syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

A ~ In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

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 consists of trauma-induced paralysis of specific cranial nerves. d. MG is a viral infection of the dorsal root of sensory nerve fibers.

A ~ 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.

A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care? a. I can scratch with a coat hanger. b. I should feel my fingers for warmth. c. I will keep the cast clean and dry. d. I will return to have the cast removed.

A ~ Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurses best response? a. This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke. b. This timing prevents your blood sugar level from dropping too low and causing you to be at risk for falling. c. These drugs are very irritating to your stomach and could cause ulcers if taken too long before meals. d. These drugs cause nausea and vomiting. By waiting a while after you take the medication, you are less likely to vomit.

A ~ Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily. The medication has no effect on blood glucose levels, ulcers, or nausea.

A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client? a. Sudden onset of shortness of breath b. Swelling of the lower extremities c. Lower abdominal tenderness d. Decreased urinary output

A ~ The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs. The other symptoms are not likely to occur or are not related to removal of the thymus.

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client? a. Inability to perform the six cardinal positions of gaze b. Lateralization to the affected side during the Weber test c. Absent deep tendon reflexes d. Impaired stereognosis

A ~ The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur? a. Epinephrine b. Atropine sulfate c. Diphenhydramine d. Neostigmine bromide

B ~ Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug. The other medications are not appropriate for complications of this test.

The intensive care nurse is caring for a client who has Guillain-Barr syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurses priority action? a. Place the client in a high Fowler's position. b. Prepare the client for elective intubation. c. Administer oxygen via a nasal cannula. d. Auscultate for breath sounds.

B ~ Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barr syndrome? a. Nerve impulses are not transmitted to skeletal muscle. b. The immune system destroys the myelin sheath. c. The distal nerves degenerate and retract. d. Antibodies to acetylcholine receptor sites develop.

B ~ In Guillain-Barr syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed. The nerves do not degenerate and retract.

The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurses best action? a. Place the client in high Fowler's position. b. Document the finding. c. Assess the corneal reflex. d. Notify the health care provider.

B ~ Loss of motor and sensory function after complete trigeminal nerve dissection is normal. No intervention is necessary.

The nurse teaches a client with Guillain-Barr syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching? a. I need to see a lawyer because I do not expect to recover from this disease. b. I will have to take things slowly for several months after I leave the hospital. c. I expect to be able to return to work in construction soon after I get discharged. d. I wonder if my family will be able to manage my care now that I am paralyzed.

B ~ Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client

C ~ 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 who has Guillain-Barr syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt? a. Palpable distal pulses b. A pink, warm extremity c. The presence of a bruit d. Shunt pressure higher than 25 mm Hg

C ~ Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the client's vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation

C ~ Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.

The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe? a. Excruciating pain b. Decreased mobility c. Controllable facial twitching d. Increased talkativeness

C ~ Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs. Sensory and mobility deficits are not associated with trigeminal neuralgia.

A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center? a. Avoid having teeth pulled for 1 year. b. Brush your teeth with a soft toothbrush. c. Do not use harsh chemicals on your face. d. Inform your dentist of this procedure.

C ~ The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan? a. Cut all calluses and corns from your feet as soon as you notice them. b. Your balance will be steadier if you go barefoot while at home. c. Use a thermometer to check the temperature of bath water. d. Avoid using lotion on the feet and legs.

C ~ The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn. Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands. The client should be taught to wear shoes at all times, to assess feet and legs daily, to keep skin moist and clean, and not to cut calluses or corns from the feet.

The nurse assesses a client who has Guillain-Barr syndrome. Which clinical manifestation does the nurse expect to find in this client? a. Ophthalmoplegia and diplopia b. Progressive weakness without sensory involvement c. Progressive, ascending weakness and paresthesia d. Weakness of the face, jaw, and sternocleidomastoid muscles

C ~ The most common clinical pattern of Guillain-Barr syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward. The other manifestations are not associated with Guillain-Barr syndrome.

The nurse teaches a client who has Guillain-Barr syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching? a. I can use the button on the pump as often as I want to get more pain medication. b. Aspirin will provide the best relief from my pain associated with this disease. c. A combination of morphine and distraction helps bring me relief right now. d. I should not have any pain as a result of impaired motor and sensory neurons.

C ~ Typical pain from GBS often is not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects. Patient-controlled analgesia (PCA) pumps should be set with appropriate doses and limits.

The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process? a. Elevated serum calcium level b. Decreased thyroid hormone level c. Decreased complete blood count d. Elevated acetylcholine receptor antibody levels

D ~ Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels. The other laboratory results are not associated with myasthenia gravis.

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 pounds in 1 month

D ~ 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.