SPINAL CORD / PERIPHERAL NS

Which ocular or facial signs/ symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? A) Weakness & Fatigue B) Ptosis & diplopia C) Breathlessness & dyspnea D) Weight loss & Dehydration

B

Which surgical procdure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the s/s of the disease process? A) There is no surgical option B) A transsphenoidal hypophysectomy C) A thymectomy D) An adrenalectomy

C

The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal?I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."

1 Clients with this syndrome usuallyhave a full recovery, but it may take upto one (1) year. 2. Only about 10% of clients are left with permanent residual disability. 3. This is "passing the buck." The nurse should answer the client's question honestly, which helps establish a trusting nurse-client relationship. 4. This indicates the nurse does not under-stand the typical course for a client diagnosed with Guillain-Barré syndrome

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.

1 Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate. 2. A Glasgow Coma Scale is used for clients with potential neurological deficits and used to monitor for increased intracranial pressure. 3. Babinski's reflex evaluates central nervous system neurological status, which is not affected with this syndrome. 4. Vital signs are a part of any admission assessment but are not a specific assessment intervention for this syndrome

The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess?Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.

1.Muscle flaccidity is a hallmark symptom of MS. 3.Dysmetria is the inability to control muscular action characterized by overestimating or under estimating range of movement. 4.Fatigue is a symptom of MS. 5.Dysphagia, or difficulty swallowing, is associated with MS. 2. Lethargy is the state of prolonged sleepiness or serious drowsiness and is not associated with MS.

The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome,so only fathers can pass it on.

1.The exact cause of MS is not known,but there is a theory stating a slow virus is partially responsible. A failure of apart of the immune system may also beat fault. A genetic predisposition involving chromosomes 2, 3, 7, 11, 17, 19, and X may be involved. 2. There is some evidence supporting a genetic component involved in developing MS. 3. A specific gene has not been identified to know if the gene is recessive or dominant. 4. The X chromosome, not the Y chromosome,may be involved.

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on .2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.

2 The client will not be able to use the arms as a result of the paralysis but can blink the eyes as long as the nurse asks simple "yes-or-no" questions. 1.The ascending paralysis has reached the client's respiratory muscles; therefore, the client will not be able to use the hands to write. 3. A speech therapist will not be able to help the client communicate while the client is on the ventilator. 4. The ascending paralysis has reached the respiratory muscles; therefore, the client will not be able to use the hands to push the call light

The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.

2 The client with Guillain-Barré syndrome will not be able to move the extremities; therefore, preventingmuscle atrophy is an appropriate long-term goal 1. This is an appropriate long-term goal for the client problem "impaired skin integrity." 3. The client will not be able to move the extremities. Therefore, the nurse will have to do passive range-of-motion exercises;this is an intervention, not a goal. 4. This is a nursing intervention, not a goal,and the client should be turned while sleeping unless the client is on a special immobility bed

Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."

2 This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits. 1. Visiting a foreign country is not a risk factor for contracting this syndrome. 3. This syndrome is not a contagious or a communicable disease. 4. Taking herbs is not a risk factor for developing Guillain-Barré syndrome

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3 Rationale:The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently .4. Provide supplemental dietary sodium with the client's meals.

3.Steroids interfere with glucose metabolism by blocking the action of insulin;therefore, the blood glucose levels should be monitored. 1. Steroid medications increase gastric acid;therefore, a proton pump inhibitor is an appropriate medication for the client. 2. Cultures are ordered prior to administer-ing antibiotics, not steroids. 4. Steroid medications cause the client to retain sodium; therefore, a low-sodiumdiet should be encouraged

The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two(2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"

3.These are clinical manifestation of MS and can go un diagnosed for years be-cause of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS. 1. MS does not affect the menstrual cycle. 2. A rash across the bridge of the nose suggests systemic lupus erythematosus 4. Taking birth control medications should not produce these symptoms or the pattern of occurrence.

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4 Ascending paralysis is the classic symptom of Guillain-Barré syndrome 1. These signs/symptoms, along with sleep disturbances and nervousness, support the diagnosis of Creutzfeldt-Jakob disease. 2. These signs/symptoms support the diagnosis of Parkinson's disease. 3. These are signs/symptoms of trigeminal neuralgia.

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.

4 Guillain-Barré syndrome has ascendingparalysis causing respiratory failure.Therefore, breathing pattern is priority. 1. Safety is an important issue for the client,but this is not the priority client problem. 2. The client's psychological needs are important, but psychosocial problems are not priority over physiological problems. 3. Clients with this syndrome may have choking episodes and are at risk for inability to swallow as a result of the disease process, but this is not the priority nursing problem because weight loss is not an expected complication of this syndrome.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4 Rationale: Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery. Strategic Words

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Nasal cannula and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray

4 Rationale:The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia

4.Dysphagia is a common problem of clients diagnosed with multiple sclerosis,and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia. 1. These are clinical manifestations of multiple sclerosis and are expected. 2. These are expected clinical manifestations of multiple sclerosis. 3. These are expected clinical manifestations of multiple sclerosis.

The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.

4.The client should make personal choices about end-of-life issues while it is possible to do so. This client is progressing toward immobility and all the complications related to it. 1. The problem is grieving R/T loss of functioning. Assistive devices will not prevent loss of functioning and do not address grieving. 2. A legal power of attorney is for personal property and control of financial issues,which is not the focus of the nurse's care. A legal power of attorney for health care maybe appropriate. 3. The nurse should and must discuss end-of-life issues with the client and does not need to contact the hospital chaplain.

The nurse and a licensed practical nurse (LPN) are caring for a group of clients.Which nursing task should not be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bed rest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.

4.The nurse should not assign assessing,teaching, or evaluation to the LPN. Evaluating the client's ability to per-form self-catheterization should not beassigned to the LPN

The client diagnosed w/ myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? A) discuss ways to help prevent choking episodes B) Explain how to care for a client on a ventilator C) Teach how to perform passive ROM exercises D) Demonstrate how to care for the client's feeding tube

A

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.40, PaO288, PaCO235, and HCO324.

A pulse oximeter reading of less than 93% warrants immediate intervention;a 90% peripheral oxygen saturation indicates a PaO2 of about 60 (normal,80 to 100). When the client is placed on the ventilator, this should cause the client's oxygen level to improve. 1. The rate of ventilation is usually 12 to 15 breaths per minute in adults who are on ventilators, so this rate does not require immediate intervention. 2. A manual resuscitation (Ambu) bag must be at the client's bedside in case the ventilator malfunctions; the nurse must bag the client. 4. These ABGs are within normal limits and do not warrant immediate intervention

The client diagnosed w/ MG is admitted w/ an acute exacerbation. Which interventions should the nurse implement? SELECT ALL APPLY. A) Assist the pt. to turn and cough every 2 hrs B) Place client in high/ semi fowlers C) assess client's pulse ox reading every shift D) Plan meals to promote medication effectiveness E) Monitor client's serum anticholinesterase levels

A,B,D

A patient with low back pain asks why nerve conduction studies are prescribed. What explanation should the nurse provide to the patient relative to this diagnostic test? 1) "It measures damage to nerves." 2) "It shows pressure on nerves from herniated disks." 3) "It measures electrical impulses within muscle tissue." 4) "It shows the structure of the vertebrae and joint outlines."

ANS: 1 1 Nerve conduction studies (NCS) measure the electrical nerve impulse that indicates damage to the nerve. 2 A myelogram shows pressure on the spinal cord or nerves from herniated disks. 3 Electromyography (EMG) measures the electrical impulse within muscle tissue. 4 X-rays show the structure of the vertebrae and joint outlines.

A patient with amyotrophic lateral sclerosis (ALS) is being prepared for discharge. What teaching would be essential for the family to receive prior to taking the patient home? Select all that apply. 1) Skin care 2) Aspiration precautions 3) Recognizing exacerbations 4) Lower extremity circulation 5) Reporting changes in continence

ANS: 1, 2, 4 1. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include pressure ulcers. 2. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include aspiration of food or fluid, respiratory failure, and pneumonia. 3. Exacerbations occur with multiple sclerosis and not ALS. 4. Amyotrophic lateral sclerosis is a progressive disease that leads to the inability to move. Complications include deep vein thrombosis (DVT) and pulmonary embolism (PE). 5. Changes in continence would be a potential complication of a herniated disk.

A patient with multiple sclerosis is developing speech difficulties. What should the nurse realize as being the reason for this new manifestation? 1) Depression 2) Medications 3) Nerve regeneration 4) Mental status changes

ANS: 2 1 Depression is an adverse effect of the disease. It does not cause speech deficits. 2 Speech defects due to muscle weakness may be due to medications. 3 Nerve regeneration would improve speech. 4 Mental status changes is an adverse effect of the disease. It does not cause speech deficits.

The nurse is assessing a patient with multiple sclerosis. What should the nurse expect to assess in this patient? Select all that apply. 1) Anxiety 2) Dizziness 3) Double vision 4) Unsteady gait 5) Electric shocks with head movement

ANS: 2, 3, 4, 5 1. Anxiety is not an identified manifestation of multiple sclerosis. 2. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes dizziness. 3. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes double vision. 4. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes unsteady gait. 5. Depending on the location of the affected nerve fibers, a manifestation of multiple sclerosis includes electric shocks with head movement.

A patient is admitted for diagnosis and treatment of ongoing spasticity and flaccidity of the extremities. Which diagnostic test should the nurse expect to be prescribed that will definitively determine this patient's health problem? 1) MRI of the neck 2) CT scan of the head 3) A variety of tests will be ordered to help rule out other causes 4) Analysis of cerebrospinal fluid from a lumbar puncture

ANS: 3 1 An MRI of the neck may be completed to rule out nerve compression. 2 A CT scan of the head may be completed to rule out masses or other structural abnormalities causing the patient's symptoms. 3 No single test can be used to diagnose ALS; therefore, a complete history and physical examination must be performed by the health-care provider. 4 Analysis of the cerebrospinal fluid will be done; however, this will not definitively diagnose the patient with ALS.

A patient with multiple sclerosis is admitted for treatment of clinical manifestations. What should the nurse expect to be prescribed for this patient? 1) Corticosteroids 2) Beta interferons 3) Muscle relaxants 4) Immunosuppressive agents

ANS: 3 1 Corticosteroids are used to treat attacks. 2 Beta interferons are used to modify the disease course. 3 Medications used to treat clinical manifestations include muscle relaxants. 4 Immunosuppressive agents are used to modify the disease course.

A patient receives a definitive diagnosis of multiple sclerosis. What finding occurred to validate this diagnosis? 1) Onset of double vision 2) Loss of bowel and bladder control 3) Numbness and tingling of one limb 4) MRI changes in two separate locations

ANS: 4 1 Double vision is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 2 Loss of bowel and bladder control is a manifestation of a herniated disk. 3 Numbness and tingling of one limb is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease. 4 For a definitive diagnosis multiple sclerosis, the patient must have MRI changes in at least two separate locations.

The nurse is caring for a patient with multiple sclerosis. What should the nurse do to increase venous return, prevent stiffness, and maintain muscle strength and endurance? 1) Administer interferon 2) Administer corticosteroids 3) Turn and reposition every two hours 4) Encourage range-of-motion exercises

ANS: 4 1 Interferon decreases exacerbations and slows disease progression. 2 Corticosteroids decreases the inflammatory processes associated with the flare. 3 Turning and repositioning every two hours prevents skin breakdown. 4 Range-of-motion exercises increases venous return, prevents stiffness, and maintains muscle strength and endurance.

A client with amyotrophic lateral sclerosis is prescribed riluzole (Rilutek). What statement indicates additional teaching is required about the effects of this medication? 1) "This will cure my disease." 2) "This will help me stay awake." 3) "This will stop my bladder spasms." 4) "This will increase the progression of my disease."

ANS: 4 1 Riluzole (Rilutek) does not repair damaged neurons but has been shown both to increase survival and to extend the period without the need for ventilator support. 2 Analeptics improve wakefulness. 3 Antispasmodics improve bladder spasms. 4 Riluzole (Rilutek) is the first drug approved to slow disease progression.

A patient is experiencing increasing flaccid upper arms while the lower extremities periodically cramp and contract. On which health problem should the nurse focus when assessing this patient? 1) Brain tumor 2) Spinal cord tumor 3) Multiple sclerosis 4) Amyotrophic lateral sclerosis (ALS)

ANS: 4 1 The manifestations of a brain tumor will depend upon the location of the mass in the cerebrum. 2 The manifestations of a spinal cord tumor will depend upon the location of the mass within the cord. 3 Both spasticity and flaccidity do not need to be present to diagnose multiple sclerosis. 4 To be diagnosed with ALS, patients must have clinical manifestations of both upper and lower motor neuron damage that cannot be attributed to other causes. Upper motor neuron damage is associated with spasticity, while lower motor neuron damage is characterized by flaccidity.

A patient with multiple sclerosis experiences exacerbations of new symptoms that last a few days and then disappear. Which type of multiple sclerosis is this patient most likely experiencing? 1) Relapsing-remitting 2) Primary progressive 3) Progressive relapsing 4) Secondary progressive

ANS:1 1 In relapsing-remitting multiple sclerosis, relapses or exacerbations occur during which new symptoms appear and old ones worsen or reappear; these relapses can last days or months. 2 Primary progressive multiple sclerosis has gradual progression with no remissions. 3 Progressive relapsing multiple sclerosis has a gradual worsening of symptoms from onset, and the relapses may or may not have recovery. 4 Secondary progressive multiple sclerosis is when the patient initially had relapsing-remitting but it gradually becomes worse.

Which of the following symptoms you as the nurse expect to see in the patient with primary progressive multiple sclerosis? (Select All that Apply): A) Unilateral Vision Loss B) Fatigue C) Diarrhea D) Intention tremors E) Paralytic ileus

Answer: A, B and D.

The client is experiencing a myasthenic crisis. Which of the following is a priority action of the following ordered actions? A) Insert NG tube B) Administer Ativan C) Monitor I&O D) Immediately stop anticholinesterase medications

Answer: A. Inserting the NG tube is the priority because it will help reduce risk for aspiration. The patient experiencing a myasthenic crisis is at a large risk for respiratory failure due to dysphagia and extreme muscle weakness. All priority actions should be focused on respiratory assessment and support. Ativan and any other sedating medication should NEVER be administered. Stopping anticholinesterase medications is associated with a cholinergic crisis. Monitoring I&O is important, but not as important as NG tube

You are teaching your patient diagnosed with myasthenia gravis about treatments. Which of the following statements, if made by the patient indicates the need for further teaching? A) Plasmapheresis is way to reduce symptoms but will need to be done every day B) A thymectomy is a removal of my thymus gland and will show some immediate relieving of my symptoms C) Corticosteroids can be used for short periods of time to help improve my symptoms, but it isn't good for long periods of time D) I need to take my Mestinon four times a day at the same time each day.

Answer: B. A thymectomy may help reduce symptoms, but the effects may not be seen for many months after surgery. Plasmapheresis is the removal of antibodies from blood plasma. It must be done daily for a period of time. Corticosteroids are mostly used for short periods of time unless the patient is experiencing ocular complications. Pyridostigmine bromide (Mestinon) is divided into several doses and should be taken at the same time daily

The nurse needs to monitor Cynthia for which complication of MS? A. Intolerance to cold B. Myopia C. Muscle spasms D. Tinnitus

Answer: C Rationale: Muscle spasms are a common complica- tion of MS; loss of muscle tone causes stiffness and spasms

The patient with myasthenia gravis is complaining about dealing with muscle weakness. Which of the following could the nurse do for this patient? A) Administer antispasmodic medication B) Teach the patient to do physical exercise for several hours each day to help strengthen muscles C) Teach the patient it is important to avoid all forms of physical activity whenever possible D) Help the patient form a plan to take medications on time

Answer: D. Taking medications at the same time each day will help reduce the exacerbation of muscle weakness. Antispasmodic medications are not indicated for this patient. Exercising for that much time each day will worsen muscle weakness and fatigue and is not feasible. The patient does not need to avoid all forms of physical activity. They need to time out physical activity with peaks of the medication in order to conserve energy.

Your patient has been diagnosed with MS. You are teaching her about how to reduce muscle spasticity. Which of the following statements, if made by the patient would indicate the need for further teaching? A) Daily exercise, including weight bearing can help relieve spasticity B) My stretching routine can help with the spasms C) Taking Baclofen may help relieve these painful spasms in my legs D) At the end of a day, taking a nice hot bath may relieve the muscle spasms

Answer: D. The patient with MS should never use hot water for a bath due to sensory deficits. All other answers can help with muscle spasms. Warm compresses can be used to relieve muscle spasms.

9. When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are abse

Correct Answer: B Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.

Correct Answer: B Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).

Correct Answer: D Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

Correct Answer: D Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

The male client with MG is undergoing plasmapheresis at the bedside. Which assessment data would warrant immediate intervention by the nurse? 1. The client complains of being lightheaded and dizzy. 2. The client can smile and clamp his teeth together. 3. The client states that his leg cramps have gone away. 4. The client has a small hematoma at the vascular access site.

Correct answer 1: Hypovolemia is a complication of plasmapheresis, especially during the procedure when up to 15% of the blood volume is in the cell separator. The nurse should immediately assess for shock. All other options are expected.

The client diagnosed with MG is being discharged home. Which intervention should the nurse teach the significant other? 1. Discuss how to perform the Heimlich maneuver. 2. Explain how to perform oral hygiene on a conscious client. 3. Teach how to perform isometric exercises. l 4. Demonstrate correct hand placement for chest compressions.

Correct answer 1: The client is at risk for choking, and knowing specific measures to help the client helps decrease the client's as well as significant other's anxiety and promotes confidence in managing potential complications. The client should perform oral care. The client should perform isotonic exercises, not isometric exercises, and the client is not at an increased risk for cardiac complications, so teaching about chest compression is not necessary.

Which statement by the client supports the diagnosis of myasthenia gravis (MG)? 1. "I have weakness and fatigue in my feet and legs." 2. "My eyelids droop, and I see double everything." 3. "I get chest pain and faint after I walk in the hall." 4. "I gained 3 pounds this week, and I am spitting up pink frothy sputum."

Correct answer 2: These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral double vision. Weakness and fatigue of upper body muscle occur with MG. Option 3 is angina. Option 4 is heart failure.

Which response to the Tensilon (edrophonium chloride) injection indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is reduced amplitude of electrical stimulation in the muscle. 3. The anti-acetylcholine receptor antibodies are present. 4. The client shows a marked improvement of muscle strength.

Correct answer 4: Clients with myasthenia gravis show a significant improvement of muscle strength that lasts approximately 5 minutes when Tensilon (edrophonium chloride) is injected.

The client is being evaluated to rule out myasthenia gravis & being administered the Tensilon test. Which response to the test indicates the client has MG? A) The client has no apparent change in the assessment data B) This is increased amplitude of electrical stimulation in the muscle C) The circulating acetylcholine receptor antibodies are decreased D) The client shows a marked improvement of muscle strength

D

The client w/ MG is admitted to the emergency room with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing cholinergic crisis? A) The serum assay of circulation ACH receptor antibodies is increased B) The client's symptoms improve when administering cholinesterase inhibitor C) Clients BP, pulse, and RR improve after IV fluid D) The tensilon test does not show improvement in the client's muscle strength

D This assessment datum indicatesa myasthenic crisis that is due to undermedication,missed doses of medication, or developing an infection.Serum assays are useful in diagnosing thedisease, not in identifying a crisis. Vital signs donot differentiate the type of crisis. No improvementafter Tensilon indicates a cholinergic crisis, not amyasthenic crisis.