NUR-144 Multiple Sclerosis Test 2

A nurse provides teaching for a 25-year-old patient who will receive mitoxantrone [Novantrone] for worsening relapsing-remitting multiple sclerosis. Which statement by the patient indicates a need for further teaching? a. "I may experience cardiac side effects several years after receiving this drug." b. "I should report fever, chills, cough, and hoarseness immediately." c. "I will need an infusion of this medication once weekly." d. "I will need a liver function test and a pregnancy test before each dose."

ANS: C Mitoxantrone is given as an infusion once every 3 months. Cardiac side effects may become apparent during treatment or up to years after discontinuation of the drug. Fever, chills, cough, and hoarseness are signs of infection and should be reported immediately. LFTs and a pregnancy test should be done before each infusion.

. A patient has been newly diagnosed with multiple sclerosis (MS), and the nurse provides teaching about the medications for the disease. Which statement by the patient indicates a need for further teaching? a. "I may need to take additional drugs at times of acute relapse." b. "I will need to take medication indefinitely." c. "If medication is begun early, permanent remission can be achieved." d. "Some symptoms may need to be managed with symptom-specific drugs."

ANS: C Drug therapy can reduce the frequency and severity of relapses, maintain quality of life, and prevent permanent damage to axons, but it does not produce permanent remission. Patients may need to take additional drugs during times of relapse and will need to take medications indefinitely. Some symptoms may be managed with symptom-specific drugs.

Immunomodulator drugs have shown effectiveness for what? (Select all that apply.) a. Preventing the development of MS b. Primary progressive MS c. Progressive-relapsing MS d. Relapsing-remitting MS e. Secondary progressive MS

ANS: C, D, E Immunomodulators can be used in progressive-relapsing MS, relapsing-remitting MS, and secondary progressive MS but not to prevent MS from developing or to treat primary progressive MS.

A patient has received an initial dose of glatiramer acetate [Copaxone] for relapsing-remitting multiple sclerosis. The nurse notes that the patient appears flushed and anxious and has urticaria. The patient reports palpitations, chest pain, and a feeling of laryngeal constriction. What will the nurse do? a. Obtain an order for epinephrine to treat a hypersensitivity reaction. b. Prepare to provide cardiorespiratory support. c. Report a possible cardiotoxic episode to the provider. d. Stay with the patient until this self-limiting episode passes.

ANS: D About 10% of patients taking glatiramer acetate experience a self-limited postinjection reaction characterized by flushing, palpitations, severe chest pain, anxiety, laryngeal constriction, and urticaria; the episode usually lasts 15 to 20 minutes. No treatment is required, but the nurse should stay with the patient to help alleviate anxiety associated with this reaction. Epinephrine is not indicated. Cardiorespiratory support is not necessary. This does not represent a cardiotoxic reaction.

A patient administers interferon beta-1a SQ [Rebif] 22 mcg/0.5 mL three times each week. The patient calls the nurse to report unrelieved itching and erythema at the injection site, despite the use of topical hydrocortisone for several weeks. What will the nurse tell this patient to do? a. Apply ice to the injection site before and after the injection. b. Ask the provider to reduce the dose of interferon beta to 8.8 mcg/0.2 mL. c. Discuss using a prescription-strength hydrocortisone product with the provider. d. Take oral diphenhydramine [Benadryl].

ANS: D Oral diphenhydramine can help reduce itching and erythema. Ice is used to control pain and should be used before the injection; warm, moist compresses are used after the injection. Reducing the dose of interferon will not reduce the local reaction. Continuous use of topical steroids is not recommended because of the risk of skin damage.

A patient has been diagnosed with multiple sclerosis (MS) for 10 years and has a history of 3 periods of neurologic dysfunction lasting several weeks separated by long periods of full recovery. In the past 6 months, the patient has had a prolonged period of neurologic dysfunction without remission. The nurse understands that the patient may have which MS subtype? a. Primary progressive MS b. Progressive-relapsing MS c. Relapsing-remitting MS d. Secondary progressive MS

ANS: D Secondary progressive MS occurs when a patient with relapsing-remitting MS develops steadily worsening dysfunction with or without plateaus or acute exacerbations, or minor remissions. Within 10 to 20 years of onset, about 50% of patients with MS will develop this type. Primary progressive MS occurs when symptoms grow progressively more intense from the onset. Progressive-relapsing MS is similar to primary progressive MS, but with acute exacerbations imposed on the steadily worsening symptoms. Relapsing-remitting MS is the most common initial presentation, which is characterized by recurrent, clearly defined episodes of symptoms with periods of remission with relapse occurring approximately twice every 3 years.

A patient is about to begin therapy with fingolimod [Gilenya] to treat multiple sclerosis. The nurse learns that the patient has not had chickenpox or the varicella zoster virus (VZV) vaccine. What will the nurse do? a. Advise the patient to avoid individuals with chickenpox. b. Give the VZV vaccine with the initial dose of fingolimod. c. Give the VZV vaccine and tell the patient to begin using fingolimod in 1 month. d. Obtain an order for a VZV antibody test

ANS: D Patients who have not had chickenpox or the VZV vaccine should be tested for VZV antibodies before receiving fingolimod. It is not correct to advise patients to avoid people with chickenpox, because this disease is endemic. Patients who do not have VZV antibodies should receive the VZV vaccine 1 month before beginning the fingolimod. The VZV vaccine should be given only to those who do not have VZV antibodies.

Which statement made by a patient indicates a need for further teaching by the nurse about reducing injection site reactions from interferon beta? "I need to rotate my injection sites, so I'll need to keep a record of them." "I will apply hydrocortisone ointment to the injection site if it is itchy." "Applying a warm compress before giving the injection will reduce the risk of pain at the site." "I can take over-the-counter Benadryl if the injection site itches and is red."

Applying a warm compress before giving the injection will reduce the risk of pain at the site." Brief application of ice rather than warm compress application is indicated prior to injection. Warm compresses may be helpful following the injection. Injection sites should be rotated to decrease discomfort. Itching and erythema can be reduced by topical application of hydrocortisone or oral diphenhydramine.

A patient newly diagnosed with MS asks the nurse how a person gets this disease. Which response by the nurse is most accurate and appropriate? "Multiple sclerosis is a congenital condition that typically manifests itself in late adulthood." "Multiple sclerosis is a disease believed to be caused by exposure to drugs during a mother's pregnancy." "This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." "This disease is most often caused by an increase of rapidly dividing cells in the central nervous system."

"This is an autoimmune disease that occurs in people with certain genetic traits when they are exposed to some environmental trigger factor." Although the exact cause is unknown, MS is believed to have a genetic link. Susceptible individuals have an autoimmune response when exposed to environmental or microbial factors. It is more common among first-degree relatives of individuals who have the disease and is more prevalent among Caucasians. It also is more common in cooler climates, with increased incidence moving away from the equator. MS may also be associated with the Epstein-Barr virus, human herpesvirus 6, and Chlamydia pneumonia.

The female client diagnosed with multiple sclerosis (MS) tells the nurse, "I am having problems having regular bowel movements." Which statement by the client indicates the client needs more medication teaching? 1. "I am taking a Dulcolax tablet every day." 2. "I am taking a fiber laxative daily." 3. "I take the stool softener Colace at bedtime." 4. "I keep a glass of water with me at all times."

#1 Dulcolax is a stimulant laxative and should not be taken every day because it will cause a decrease in the bowel tone. A client with MS already has difficulty with bowel tone.

The client with multiple sclerosis is being treated with the biologic response modifier interferon beta-1a (Avonex). Which diagnostic test would the nurse monitor to determine the effectiveness of the medication? 1. The cerebrospinal fluid white blood cell count. 2. The magnetic resonance imaging (MRI) scan. 3. An electromyogram (EMG). 4. An electroencephalogram (EEG).

#2 Interferon can reduce the frequency of relapse by 30% and decrease the appear- ance of new lesions on the MRI by 80%.

The client diagnosed with multiple sclerosis is prescribed baclofen (Lioresal), an antispasmodic. Which data is most important for the nurse to assess? 1. The client's serum baclofen levels. 2. The client's urinary output. 3. The client's pain, muscle rigidity, and range of motion. 4. The client's BUN and creatinine levels.

#3 Baclofen is administered to treat the spasticity associated with MS. The nurse should assess for muscle spas- ticity, rigidity, movement, and pain to determine the effectiveness of the medication.

A patient who stopped taking teriflunomide [Aubagio] 1 year prior tells the nurse that she has just found out she is pregnant. Which action by the nurse is correct? a. Contact the provider to obtain an order for serum drug levels. b. Reassure the patient that her fetus should be safe. c. Suggest that she consider an abortion. d. Tell her that she will not be able to nurse her baby when it is born.

ANS: A testbanks_and_xanax Women taking teriflunomide should be tested prior to beginning the drug to rule out pregnancy and should be counseled to use a reliable form of birth control while taking it since the drug is listed as pregnancy category X and can cause serious birth defects. The drug can stay in the system for up to 2 years. Women who become pregnant should be evaluated to determine serum drug levels and bile acid sequestrants or activated charcoal may be given to enhance drug elimination. The nurse cannot assure her that her fetus is safe and should not counsel abortion.

A patient who has recently begun taking interferon beta reports feeling depressed. Which action by the nurse is correct? a. Notify the provider of these symptoms. b. Reassure the patient that these symptoms will subside. c. Request an order for an antidepressant medication. d. Suggest counseling to discuss the effects of this chronic disease.

ANS: A Interferon beta may promote or exacerbate depression and some patients may experience suicidal ideation or may attempt suicide. The provider should be notified so that the patient may be monitored and a reduction of dose may be required. Reassuring the patient is not correct because the symptoms may worsen. Patients experiencing depression should be referred to a psychiatrist for treatment. The depression is caused by the drug and should not be considered a normal effect of the disease.

A patient is being treated with interferon beta-1a [Avonex] for relapsing-remitting MS. The patient calls the clinic to report headache, fever, chills, and muscle aches after administering a dose. What will the nurse recommend? a. Acetaminophen or ibuprofen b. Asking the provider to order a complete blood count (CBC) c. Coming to the clinic for evaluation for leukoencephalopathy d. Discontinuing the drug immediately

ANS: A Patients treated with interferon beta can experience flulike reactions that diminish over time. Acetaminophen or ibuprofen may be used to treat symptoms. A CBC is not indicated. Leukoencephalopathy is a side effect of natalizumab, not interferon beta. It is not necessary to discontinue the drug.

A patient with multiple sclerosis is to begin treatment with interferon beta. The patient comes to the clinic to have pretreatment laboratory tests. Which statement by the patient indicates a need for further teaching about these tests? a. "After the first year of treatment, I will need once yearly blood work." b. "I will need to have lab tests done every 3 months for the first year." c. "If my liver function tests are abnormal, I will need to stop using this drug." d. "These lab tests will measure liver and bone marrow function."

ANS: A Patients treated with interferon beta require evaluation of bone marrow function with CBCs and of liver function with liver function tests (LFTs) at the beginning of therapy for baseline, every 3 months for a year, and then every 6 months thereafter. Abnormal LFTs warrant discontinuation of the drug

A patient has begun taking dimethyl fumarate [Tecfidera] to treat relapsing MS and calls the clinic to report flushing of the skin with itching and burning sensations. What will the nurse recommend to this patient? a. "Take a non-enteric-coated aspirin 30 minutes before each dose." b. "The provider will order an antihistamine to treat this symptom." c. "Try taking the medication on an empty stomach." d. "You should notify the provider immediately."

ANS: A The most common side effect of dimethyl fumarate is flushing, which decreases over time. Patients should be counseled to take a non-enteric-coated aspirin 30 minutes prior to the dose and to take the medication with food. Antihistamines are not indicated. It is not a serious symptom and the provider does not need to be notified.

Which drugs may be selected by the provider for initial treatment for a patient who is diagnosed with relapsing-remitting MS? (Select all that apply.) a. Dimethyl fumarate [Tecfidera] PO b. Interferon beta 1a [Avonex] IM c. Mitoxantrone [Novantrone] IV d. Methotrexate [Rheumatrex] PO e. Teriflunomide [Aubagio] PO

ANS: A, B, D All patients with relapsing-remitting MS, regardless of age, frequency of attacks, or disability, should receive one of the immunomodulators, such as dimethyl fumarate, interferon beta 1a, or teriflunomide. Mitoxantrone is an immunosuppressant and may be added if the immunomodulator fails. Methotrexate is an immunosuppressant and is used experimentally to treat primary progressive MS.

A patient has been diagnosed with primary progressive multiple sclerosis for 1 year and reports a recent brief period of being symptom free. The nurse will tell the patient that this indicates what? a. Hope for long-term remission b. Temporary improvement c. Development of relapsing-remitting MS d. Development of secondary progressive MS

ANS: B Patients with primary progressive MS have symptoms that grow progressively more intense over time; patients may experience occasional plateaus or temporary improvement, but they do not have clear remissions. This episode does not represent hope for long-term remission or the development of a different subtype of MS.

The nurse is caring for a patient with MS who is receiving interferon beta-1a [Rebif] by subcutaneous injection. Which laboratory tests should be performed regularly in this patient to monitor for a potential adverse effect? (Select all that apply.) Blood urea nitrogen Complete blood count Hemoglobin A1c Alkaline phosphatase Immunoglobulin G levels

Complete blood count Alkaline phosphatase When monitoring a patient receiving interferon, the nurse should watch for potential adverse reactions of hepatotoxicity (alkaline phosphatase) and myelosuppression (complete blood counts). The blood urea nitrogen value is an indicator of renal function, which is not affected by interferon beta-1a. The hemoglobin A1c test is a weighted average of the glucose level over the past several months. Glucose levels are not affected by interferon beta-1a. Immunoglobulin G levels might be assessed when making the diagnosis, but they are not used to monitor for adverse effects of interferon.

Which complaint by a patient taking fingolimod [Gilenya] requires prompt evaluation by the prescriber? Hair loss Backache Dizziness and fatigue Blue-green tint to the skin

Dizziness and fatigue Fingolimod slows the heart rate and can cause bradycardia. Dizziness and fatigue may be consequences of bradycardia. Backache is an adverse effect that occurs in 12% of patients taking the medication, but it does not require prompt attention. Reversible hair loss and a blue-green tint to the skin are adverse effects of mitoxantrone [Novantrone].

The nurse is teaching a patient about a new prescription for mitoxantrone [Novantrone]. Which statement made by the patient indicates a need for further teaching? "I volunteer at a local day care center once a week." "I drink grapefruit juice with breakfast each morning." "I enjoy walking and outdoor activities in the sun." "I understand this drug may cause my urine to turn blue."

I volunteer at a local day care center once a week." Mitoxantrone can cause myelosuppression. Patients taking this drug should be advised to avoid contact with people who have infections, such as children in day care centers. The other statements are appropriate for patients taking this drug.

A patient with a history of numbness, weakness, and blurred vision recently was diagnosed with multiple sclerosis (MS). What does the nurse understand to be the underlying pathophysiology for these symptoms? An imbalance of dopamine and acetylcholine in the central nervous system Inflammation and myelin destruction in the central nervous system An inability of serotonin to bind to its receptors in the chemoreceptor trigger zone High-frequency discharge of neurons from a specific focus area of the brain

Inflammation and myelin destruction in the central nervous system The underlying pathophysiology of MS is related to myelin destruction and slowing of axonal conduction related to inflammation within the central nervous system. The demyelination leads to the characteristic neurologic symptoms associated with MS.

The nurse is caring for a patient receiving glatiramer acetate [Copaxone] for MS. Which finding, if present in this patient, could be considered a potential adverse effect of this drug? Flu-like symptoms with fever Decreased neutrophil count Jaundice and elevated bilirubin Injection site pain and redness

Injection site pain and redness Injection site reactions, such as pain, erythema, pruritus, and induration, are the most common adverse effects of glatiramer. Unlike interferon, glatiramer does not cause flu-like symptoms, myelosuppression, or hepatotoxicity, which would be indicated in the other responses.

The nurse is caring for a patient hospitalized with an acute episode (relapse) of MS. Which agent is the preferred treatment during relapse? Interferon beta-1a [Avonex] IM Methylprednisolone [Solu-Medrol] IV Glatiramer acetate [Copaxone] subQ Natalizumab [Tysabri] IV infusion

Methylprednisolone [Solu-Medrol] IV During an acute relapse episode of MS, the treatment of choice is a high-dose IV glucocorticoid, such as methylprednisolone, to reduce the inflammation and diminish symptoms. The other agents are disease-modifying drugs that are used in the long-term management of MS.

Which medications can be used to manage fatigue associated with multiple sclerosis? (Select all that apply.) Modafinil [Provigil] Clonazepam [Klonopin] Amantadine [Symmetrel] Carbamazepine [Tegretol] Dalfampridine [Ampyra]

Modafinil [Provigil] Amantadine [Symmetrel] Fatigue develops in about 90% of patients with multiple sclerosis, and the drugs most commonly used to manage this symptom include modafinil and amantadine. Clonazepam may be useful for alleviating tremor and ataxia associated with the disease. Carbamazepine, an antiepileptic drug, may be helpful for alleviating neuropathic pain. Dalfampridine may be given to improve walking.

Which medication used for the management of multiple sclerosis cannot be self-administered? Fingolimod [Gilenya] Natalizumab [Tysabri] Glatiramer acetate [Copaxone] Interferon beta-1b [Betaseron]

Natalizumab [Tysabri] Natalizumab [Tysabri] is administered by intravenous infusion over 1 hour. The patient must be observed during the infusion and also must be monitored for 1 hour after the infusion is complete. Before this medication can be prescribed and administered, everyone involved with the drug—patients, physicians, pharmacists, infusion nurses, and infusion centers—must be registered with the TOUCH Prescribing Program. The other medications can be self-administered: fingolimod (oral), glatiramer acetate, and interferon beta-1b (subcutaneous injection).

Which assessments are essential before a patient receives a second dose of mitoxantrone [Novantrone]? (Select all that apply.) Pregnancy test Echocardiogram Complete blood count T3, T4, and TSH levels Ophthalmic examination Magnetic resonance imaging (MRI)

Pregnancy test Echocardiogram Complete blood count Mitoxantrone [Novantrone] can cause a variety of adverse effects. Myelosuppression, cardiotoxicity, and fetal injury are the greatest concerns. Consequently, a pregnancy test and a complete blood count should be done, as well as an echocardiogram to determine the left ventricular ejection fraction. Thyroid function studies and MRI are not necessary. Ophthalmic examinations are necessary when the patient is experiencing macular edema, an adverse effect of fingolimod.

Natalizumab [Tysabri] is a very effective agent for treating MS. Which problem is associated with the administration of this drug, making it a second-line agent? Increased risk of sudden cardiac death Documented reports of necrotizing colitis Increased risk of Stevens-Johnson syndrome Rare cases of dangerous brain infections

Rare cases of dangerous brain infections Soon after natalizumab was released on the market, there were three reports of progressive, multifocal leukoencephalopathy. All patients who developed this problem were taking natalizumab in combination with another immunosuppressant. The drug is now available only through a specialized, carefully controlled prescribing program.

The nurse is caring for a patient with MS who is having worsening recurrent episodes of neurologic dysfunction followed by periods of partial recovery. How would this subtype be classified? Relapsing-remitting Secondary progressive Primary progressive Progressive-relapsing

Secondary progressive Relapsing-remitting MS is marked by defined episodes of neurologic dysfunction separated by periods of partial or full recovery. In secondary progressive MS, the patient with the relapsing-remitting subtype experiences declining function with or without occasional recovery of function. Primary progressive MS presents with progressive decline of function from the onset. Progressive-relapsing MS is rare and is similar to primary progressive but has acute episodes in addition to the progressively worsening dysfunction