NURS 309 Quiz 16

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 formulation a response? 1. Stimulated the cerebral cortex 2. Blocks the action of cholinesterase 3. Replaces deficient neurotransmitters 4. Accelerates transmission along neural sheaths

2. Blocks the action of cholinesterase

The 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. Ascending weakness

A patient with myasthenia gravis is experiencing cholinergic crisis. What is the major concern when caring for this patient? a. brainstem herniation b. respiratory failure c. renal failure d. hypertensive crisis

b. respiratory failure

For a patient with Guillain-Barre' syndrome, what is the expected and desired outcome of plasmapheresis? a. decreases the symptoms b. puts patient into remission c. cures almost all patients d. slows progression of disease

a. decreases the symptoms

The home health nurse sees in the patient's record that he takes riluzole. Which question is the nurse most likely to ask? a. when were you first diagnosed with amyotrophic lateral sclerosis? b. has the mediation relieved any of the symptoms caused by multiple sclerosis? c. has your acute back pain returned to the more familiar chronic pain? d. have you always had neurogenic bladder problems since your spinal cord injury?

a. when were you first diagnosed with amyotrophic lateral sclerosis?

What is the priority nursing assessment for a patient with myasthenia gravis? 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. ability to chew and swallow

The nurse is performing patient and family teaching about myasthenia gravis and medications. What important information does the nurse give during the teaching session? 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. drugs containing morphine or sedatives can increase muscle weakness

d. drugs containing morphine or sedatives can increase muscle weakness

To assess the hypoglossal nerve (cranial nerve XII), what will the nurse ask the patient to do? a. blink eyelids and raise eyebrows b. read an eye chart or newspaper c. demonstrate a deep cough d. stick the tongue straight out

d. stick the tongue straight out

The nurse is caring for a patient who has a shnt for plasmapheresis. Which intervention related to the shunt does the nurse perform? a. assess for bruit or thrill every 2-4 hours b. flush the shunt with sterile normal saline c. wrap the shunt with a protective gauze dressing d. ensure that IV fluid is infusing at prescribed rate

a. assess for bruit or thrill every 2-4 hours

The nurse is monitoring a patient with Guillain-Barre' syndrome undergoing plasmapheresis. The patient reports dizziness and has a heart rate that has dropped to 48 beats per minute. 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 d. defibrillate the patient

a. atropine IV push

The nurse is caring for a patient who has undergone plasmapheresis. Which laboratory tests must the nurse monitor in relation to this therapy? SATA a. complete blood count b. coagulation studies c. serum protein electrophoresis d. arterial blood gases e. electrolytes f. cerebral spinal fluid results

a. complete blood count b. coagulation studies e. electrolytes

What is the priority expected outcome in a patient with Guillain-Barre' syndrome? a. maintain airway patency and gas exchange b. promote communication c. manage pain and discomfort d. prevent complications of immobility

a. maintain airway patency and gas exchange

The nurse is caring for a patient who is slowly recovering from Guillain-Barre' syndrome with ascending paralysis. Which sign of physical recovery would the nurse expect to see first? a. respiratory effort improves b. gross motor of arms improves c. fine motor of fingers returns d. movement of lower legs returns

a. respiratory effort improves

A patient with myasthenia gravis 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 patient? 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. voice may become weaker or exhibit a nasal twang

An ambulatory patient has sought treatment for symptoms of Guillain-Barre' syndrome. IV immunoglobulin therapy has been prescribed. Which precaution does the nurse expect with this therapy? a. IV immunoglobulin is given concurrently with plasmapheresis b. A shunt must be placed prior to beginning the therapy c. IV immunoglobulin is slowly infused when it is started d. three or four treatments are given 1 to 2 days apart

c. IV immunoglobulin is slowly infused when it is started

A patient with Guillain-Barre' syndrome is receiving IV immunoglobulin. The nurse monitors for which major potential complication of this drug therapy? a. ventricular fibrillation b. hypertensive crisis c. anaphylaxis d. malignant hyperthermia

c. anaphylaxis

The patient with multiple sclerosis states she is bothered by diplopia. Which intervention does the nurse expect to implement? a. obtain an order for consultation or referral for corrective lenses b. teach the patient 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. application of an eye patch alternating from eye to eye every few hours

WHich intervention is appropriate to protect a patient with myasthenia gravis from corneal abrasions? a. instruct the patient to keep the eyes closed b. apply an eye patch to both eyes after breakfast c. apply lubricant gel and shield to the eyes at bedtime d. place a clean moist washcloth over the patient's eyes

c. apply lubricant gel and shield to the eyes at bedtime

Although an adverse reaction during the Tensilon challenge test is considered rare, which medication should be readily available to give as an antidote in case a patient should experience complications? a. protamine sulfate b. naloxone c. atropine sulfate d. phentolamine mesylate

c. atropine sulfate

A patient is admitted for a probably diagnosis of Guillain-Barre' syndrome but needs additional diagnostic testing for confirmation. Which test does the nurse anticipate will be ordered for this patient? a. electroencephalography b. cerebral blood flow c. electroencephalography study d. electrocardiogram

c. electroencephalography study

A patient tells the nurse, "I have the symptoms of multiple sclerosis (MS), and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employe first? a. help the patient to locate and make an appointment with a specialist b. ask the patient to describe the symptoms and past treatments c. encourage the patient to verbalize feelings and frustrations d. give the patient a brochure about the diagnosis and treatment of MS

c. encourage the patient to verbalize feelings and frustrations

Which disorder could have a similar clinical presentation to multiple sclerosis? a. amyotrophic lateral sclerosis b. spinal cord tumor c. Guillain-barre' d. quadriplegia

a. amyotrophic lateral sclerosis

The nurse reads in the patient's chart that he has myasthenia gravis with bulbar involvement. Which intervention is the nurse most likely to use? a. administer medication 45-60 minutes before meals b. assess for bowel and bladder function after meals c. assist the patient to comb hair and don shirt d. use pillows to prop patient upright when sitting

a. administer medication 45-60 minutes before meals

A patient is suspected of having myasthenia gravis, and a Tensilon challenge test has been ordered. What does the nurse do to prepare the patient for the test? a. ensure that the patient has a patent IV access b. draw a blood sample and send it for baseline analysis c. withhold food and fluids after midnight d. have the patient void before the beginning of the test

a. ensure that the patient has a patent IV access

The nurse is assessing a patient with myasthenia gravis. Which manifestations can the nurse expect to observe? SATA a. ptosis b. diplopia c. delayed pupillary responses to light d. ocular palsies e. decreases pupillary accommodation f. fatigue

a. ptosis b. diplopia d. ocular palsies f. fatigue

The nurse is teaching a patient with multiple sclerosis and her family about her exercise program. Which points must the nurse include? SATA a. range of motion exercises are an important component b. stretching should precede rigorous activity c. increased body temperature can lead to increased fatigue d. steadily increasing walking distances can lead to jogging e. stretching and strengthening exercises will be part of your program f. take your pain medication at least 30 minutes prior to exercise

a. range of motion exercises are an important component c. increased body temperature can lead to increased fatigue e. stretching and strengthening exercises will be part of your program

What can be one cause of cholinergic crisis? a. withdrawal from anticholinesterase drugs b too many anticholinesterase drugs c. some type of bacterial infection d. allergic reaction to anticholinesterase drugs

b too many anticholinesterase drugs

The nurse is caring for a patient receiving cholinesterase inhibitor drugs for myasthenia gravis. Which symptoms does the nurse immediately report to the health care provider? a. increasing loss of motor function b. ineffective nonproductive cough c. dyspnea and difficulty swallowing d. gastrointestinal side effects

c. dyspnea and difficulty swallowing

What diagnostic test is used to differentiate a cholinergic crisis from a myasthenic crisis? a. electrophysiologic studies b. repetitive nerve stimulation c. tensilon challenge testing d. cerebral spinal fluid protein level

c. tensilon challenge testing

The nurse has provided teaching to the husband of a 33 year old woman who was recently diagnosed with multiple sclerosis. Which statement by the patient's husband indicates he needs additional teaching on the course of the illness? a. "she could fall because she may lose her balance and have poor coordination." b. "eventually she will not be able tot drive because of vision problems." c. "she will probably have decreased libido and diminished orgasm." d. "as the disease progresses, she could have intermittent short-term memory loss."

d. "as the disease progresses, she could have intermittent short-term memory loss."

A patient with Guillain-Barre' syndrome ha been intubated for respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the patient for? a. tachypnea b. atrial fibrillation c. cyanosis d. bradycardia

d. bradycardia

A patient with myasthenia gravis experienced a cholinergic crisis and is currently being maintained on a ventilator. The patient received several 1-mg doses of atropine IV. What does the nurse closely monitor for? a. increasing muscle weakness b. increased salivation c. ventricular fibrillation d. development of mucus plugs

d. development of mucus plugs

The most common symptoms of myasthenia gravis are related to involvement of the levator palpebrae or extraocular muscles. Which assessment technique would the nurse use? a. use a penlight and check for pupil size and response b. stand to the patient's side and observe fro protrusion of the eyeballs c. check accommodation by moving the finger toward the patient's nose d. face the patient and instruct to open and close the eyelids

d. face the patient and instruct to open and close the eyelids

What is the nursing concept that underlies the etiology and the pathophysiology of Guillain-Barre' syndrome? a. sensroy perception b. mobility c. gas exchange d. immunity

d. immunity

The nurse is preparing to change the linens on the bed of a client who has a sacralwound infected by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) items will be used? SATA 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves

A client who has been diagnoses with possible avian influenza is admitted to the medical unit. Which prescribed action will the nurse take first? 1. Place the client in an airborne isolation room 2. Initiate infusion of 500 mL of normal saline bolus 3. Ask the client about any recent ravel to Asia 4. Obtain sputum specimen and nasal cultures

1. Place the client in an airborne isolation room

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 finding support the conclusion that these responses are related to pyridostigmine? SATA 1. Respiratory depression 2. Distention of the bladder 3. Decreased blood pressure 4. Find tremor of the fingers 5. High-pitched gurgling bowel sounds

1. Respiratory depression 3. Decreased blood 5. High-pitched gurgling bowel sounds

A client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply? 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. A decreased number of functioning acetylcholine receptor sites

A client with myasthenia graivs asks the nurse, "what is going to happen to me and to my family?" What information about 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. Chronic illness with exacerbations and remissions

A client is admitted to the hospital with diagnosis of myasthenia graivs. For which common early clinical finding should the nruse assess the client? 1. Tearing 2. Blurring 3. Diplopia 4. Nystagmus

3. Diplopia

What does the nurse understand that clients with myasthenia gravis, Guillain-Barre' syndrome, and amyotrophic lateral sclerosis (ALS) 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. Increased risk for respiratory complications

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. Ineffective coughing

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis to experience? SATA 1. Double vision 2. Resting tremors 3. Flaccid paralysis 4.Scanning speech 5. Mental retardation

1. Double vision 4.Scanning speech

A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time? 1. Fatigue 2. Inability to perform activities of daily living (ADLs) 3. decreased mobility 4. muscular weakness

1. Fatigue

A client with myasthenia gravis continues to become weaker despite treament 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 a synergistic effect 3. Overcome neostignmine resistance 4. Confirm the diagnosis of myasthenia

1. Rule out cholinergic crisis

Which infection control activity should the charge nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Screening clients for upper respiratory tract symptoms 2. Asking clients about the use of immunosuppressant medications 3. Demonstrating correct hand washing to the client's visitors 4. Disinfecting blood pressure cuffs after clients are discharged

4. Disinfecting blood pressure cuffs after clients are discharged

A nurse is caring fora client in the home who has the diagnosis of amyotrophic later 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. Semi-Fowler

The nurse is teaching the patient and family about factors that predispose the patient to episodes of exacerbation of myasthenia gravis. Which factors does the nurse mention? SATA a. infection b. stress c. sedatives d. any physical exercise e. enemas f. strong cathartics

a. infection b. stress c. sedatives e. enemas f. strong cathartics

The patient has Guillain-Barre' syndrome with ascending paralysis. What would the nurse expect to observe? a. motor weakness that starts in legs and then spreads to arms and upper body b. extensive paralysis similar to quadriplegia, but sensory function is retained c. motor weakness and fatigue that progressively worsens throughout the day d. paralysis that is worse int he upper body, particularly the arms and hands

a. motor weakness that starts in legs and then spreads to arms and upper body

A home care nurse is counseling a client with amyotrophic later sclerosis (ALS). What information should the nurse include int he discussion? SATA 1. Space activities throughout the day 2. Engage in social interactions with large groups 3. Request an 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. Space activities throughout the day 4. Anticipate the use of alternate ways to communicate

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? 1. aspiration 2. dehydration 3. Nutritional imbalance 4. Impaired communication

1. aspiration

Which statement by a client with multiple sclerosis 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. "I will take a hot bath to help relax my muscles."

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 respiration 3. Encouraging aerobic exercises to avoid muscle atrophy 4. Administering antibiotic mediation to prevent pneumonia

2. Maintaining ventilator settings to support respiration

The RN notes that a client with myasthenia gravis has an elevated temperature (102.2F [39 C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? 1. Administer an acetaminophen suppository. 2. Notify the health care provider immediately 3. Recheck vital signs in 1 hour 4. Reschedule the client's physical therapy

2. Notify the health care provider immediately

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 head of the bed 3. Perform tracheal suctioning 4. Cll the health care provider

2. Raise the head of the bed

A recently hospitalized client with multiple sclerosis 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 beside

2. Space activities throughout the day

A nurse is caring for a client with 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 clients oropharynx 3. Administer oxygen via nasal cannula 4. Place the client in the orthopneic position

2. Suction the clients oropharynx

A client with multiple sclerosis 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. Swimming

A client with Gullain-Barre' syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Observe the access site for ecchymosis or bleeding 2. Instruct the client that there will be three or four treatments 3. Weigh the client before and after the procedure 4. Assess the access site for bruit and thrill every 2 to 4 hours

3. Weigh the client before and after the procedure

An LPN/LVN. under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barre' syndrome (GBS). What observation should the LPN/LVN be instructed to report immediately? 1. Reports of numbness and tingling 2. Facial weakness and difficulty speaking 3. Rapid heart rate of 102 beats/min 4. Shallow respirations and decreased breath sounds

4. Shallow respirations and decreased breath sounds

A patient with myasthenia gravis has been referred to a surgeon for a procedure that may improve the patient's symptoms. Which brochure would the nurse prepare for the patient? a. "what is percutaneous Stereotactic Rhizotomy?" b. "How to Prepare for Your Surgical Thymectomy" c. Expected Outcomes for Microvascular Decompression" d. "Stereotactic Radiation Treatments by Gamma Knife"

b. "How to Prepare for Your Surgical Thymectomy"

The patient with Guillain-Barre' syndrome is at risk for aspiration. Which precautions must the nurse initiate to prevent aspiration? SATA a. elevate the head of the bed at least 45 degrees b. assess for dysphagia prior to giving oral fluids or medications c. teach coughing and deep breathing exercises d. have suctioning equipment available at the bedside e. turn the patient form side to side at least every 2 hours f. restrict food and fluids until exacerbation resolves

a. elevate the head of the bed at least 45 degrees b. assess for dysphagia prior to giving oral fluids or medications d. have suctioning equipment available at the bedside

The nurse is reviewing the cerebral spinal fluid (CSF) results fora patient with probably Guillain-Barre' syndrome, who has been having symptoms for several weeks. Which abnormal finding is most likely to be seen at this time? a. increase in CSF protein level b. increase in CSF glucose level c. cloud appearance of CSF d. elevation of lymphocyte count in CSF

a. increase in CSF protein level

A patient with myasthenia gravis is experienceing impaired communication related to weakness of the facial muscles. Which interventions are best in assisting the patient to communicate with the staff and family? SATA a. instruct patient to speak slowly b. use short, simple sentences c. ask yes or not questions d. use system of eye blinking e. have patient use a picture, letter, or word board f. face patient and speak clearly

a. instruct patient to speak slowly c. ask yes or not questions d. use system of eye blinking e. have patient use a picture, letter, or word board

A patient with myasthenia gravis reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is the underlying pathophysiology of this patient's symptoms? 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. limb weakness is more often proximal

The nurse is reviewing medication orders for a patient with myasthenia gravis. The patient is scheduled to receive pyridostigmine on a daily basis. What does the nurse expect regarding this drug? a. noting daily dosage change related to presenting symptoms b. administering medication 30 minutes after antacid c. monitoring for 60 minutes for a cholinergic crisis d. gradual tapering and weaning off the drug

a. noting daily dosage change related to presenting symptoms

The nurse is caring for a patient with myasthenia gravis. What problem does the nurse expect the patient to have? a. patient has more trouble with mobility when he is fatigued b. patient has difficulty sleeping, and wakes around 3:00 AM c. patient is disorientated in the late afternoon d. patient has pain that interferes with activities of daily living

a. patient has more trouble with mobility when he is fatigued

A patient with myasthenia gravis is having difficulty maintaining an adequate intake of food and fluid because of difficulty chewing and swallowing. Which task for this patient is best to delegate to unlicensed assistive personnel? a. perform daily weights b. monitor calorie counts c. ask about food preferences d. evaluate intake and output

a. perform daily weights

To maintain mobility for the patient with Guillain-Barre' syndrome, which intervention is best for the nurse to delegate to unlicensed assistive personnel? a. perform passive range of motion every 2 to 4 hours b. turn the patient every 2 hours and assess for skin breakdown c. ask the patient if he feels strong enough to go physical therapy d. assist the patient to ambulate in the hall several times during the shift

a. perform passive range of motion every 2 to 4 hours

During the shift report, the nurse learns that a patient with myasthenia gravis deteriorated toward the end of the shift and the health care provider was called. Tensilon challenge test indicated that the patient was having a myasthenic crisis. What is the priority problem for this patient? a. potential for inadequate oxygenation b. potential for decreased ability to do self care c. potential for aspiration pneumonia d. potential for increase in blood pressure

a. potential for inadequate oxygenation

A patient with myasthenia gravis has generalized weakness and fatigue and is limited in the ability perform activities of daily living (ADLs). Which nursing action is best to help this patient avoid excessive fatigue? a. schedule activities after medication administration b. schedule activities during the late afternoon or early evening c. encourage ambulation during periods of maximal strength d. instruct unlicensed assistive personnel to assist with all ADLs.

a. schedule activities after medication administration

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past, but they resoled and no medical attention was sought. Which questions does the nurse ask to assess whether the symptoms may be associated with multiple sclerosis? SATA a. "are you having persistent headaches that occur with stress?" b. "do you have persistent sensitivity to temperature?" c. "do you ever have slurred speech or trouble swallowing?" d. "are you having trouble breathing with minor exertion?" e. "has anyone in your family been diagnosed with multiple sclerosis?" f. "do you have spasms at night that wake you from your sleep?"

b. "do you have persistent sensitivity to temperature?" c. "do you ever have slurred speech or trouble swallowing?" e. "has anyone in your family been diagnosed with multiple sclerosis?" f. "do you have spasms at night that wake you from your sleep?"

A patient has been newly diagnoses with Guillain-Barre' syndrome. The nurse is teaching the patient and family about the condition. Which statement by the family indicates a need for additional teaching? a. "he could recover in 4 to 6 months." b. "he'll never be able to walk again." c. "he will receive medication for pain." d. " He will be monitored for breathing problems."

b. "he'll never be able to walk again."

A patient with multiple sclerosis is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug? a. "you must be carefully monitored for allergic reactions 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, but there is an increased risk for stroke." d. "the medication will improve your ability to walk, but it also increases the risk for seizure activity."

b. "we need to teach you how to monitor your pulse rate because this drug can cause a slow heart rate."

The nurse is performing teaching for the family of a patient with myasthenia gravis about fatigue and activities of daily living. 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. "we should do hygienic care for her to avoid undue frustration and fatigue."

The nurse is caring for a patient with myasthenia gravis who had a thymectomy. The patinet demonstrates restlessness and reports chest pain and shortness of breath. What are the priority nursing interventions? SATA a. instruct to use the incentive spirometry b. administer oxygen c. raise the head of the bed 45 degrees d. place in supine position to encourage rest e. notify the rapid response team f. prepare to administer atropine

b. administer oxygen c. raise the head of the bed 45 e. notify the rapid response team

The nurse is caring for a patient newly diagnosed with myasthenia gravis. The nurse is alert for complications related to both myasthenic crisis and cholinergic crisis. What is the priority nursing assessment for this patient? a. monitor cardiac rate and rhythm b. assess respiratory status and function c. monitor fatigue and activity levels d perform neurologic checks every 2-4 hours

b. assess respiratory status and function

The patient with multiple sclerosis has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication? a. watch the patient walk and note smoothness of movement b. check the patient's gag reflex and ability to swallow c. ask the patient to use a pencil to write a sentence d. have the patient stand and close eyes, and observe the patient for sway

b. check the patient's gag reflex and ability to swallow

Which strategies should be incorporated in the plan of care to provide emotional support for a patient with Guillain-Barre' syndrome? SATA a. limit information provided to the patient and family b. encourage the patient to verbalize feelings c. teach the patient and family about the condition d. explain al procedures and test e. allow regularly scheduled rest periods f. assess previous coping skills

b. encourage the patient to verbalize feelings c. teach the patient and family about the condition d. explain al procedures and test e. allow regularly scheduled rest periods f. assess previous coping skills

The nurse is reviewing the admission and history notes for a patient with Guillain-Barre' syndrome (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 disease

b. recent bacterial infection

The nurse is assessing a patient with a diagnosis of Guillain-Barre' syndrome. Which signs and symptoms would the nurse expect to observe? SATA a. bilateral sluggish pupil response b. sudden onset of weakness in the legs c. muscle atrophy of the legs d. change in level of consciousness e. double vision f. uncoordinated movements

b. sudden onset of weakness in the e. double vision f. uncoordinated movements

What is considered a positive diagnostic finding of a Tensilon challenge test? a. 60 minutes 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 minutes c. within 30 minutes of receiving the cholinesterase inhibitor, there is improved muscle strength that lasts for several weeks d. after the cholinesterase inhibitor is first administered, the patient will experience muscle weakness and then return to baseline

b. within 30-60 seconds after receiving the cholinesterase inhibitor, there is increased muscle tone that lasts 4-5 minutes

A patient with myasthenia gravis demonstrates a weak cough. Auscultation of the lungs reveals coarse crackles throughout the lung fields. The nurse identifies that patient is unable to cough effectively enough to clear the airway of secretions. Which intervention is best of this patient? a. low flow oxygen therapy b.chest physiotherapy c. endotracheal suction d. elective intubation

b.chest physiotherapy

The nurse asks a patient with Guillain-Barre' syndrome to smile, frown, whistle, and drink from a straw. Which cranial nerve is the nurse assessing? a. Cranial nerve I b. Cranial nerve II c. Cranial nerve VII d. Cranial nerve X

c. Cranial nerve VII

During shift report, the nurse hears that a patient with Guillain -Barre' syndrome has a decrease in vital capacity that is less than two-thirds of normal, and there is a progressive inability to clear and cough up secretion. The health care provider has been notified and is coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient? a.frequent oral suctioning b. rigorous chest physiotherapy c. elective intubation d. elective tracheostomy

c. elective intubation

A patient is receiving a cholinesterase inhibitor drug for the treatment of myasthenia gravis. What is a nursing implication for this medication that relates to patient safety? a. Monitor for orthostatic hypotension b. take the patient's apical pulse prior to administration c. feed meals 45-60 minutes after administration d. encourage at least 8 glasses of water each day

c. feed meals 45-60 minutes after administration

The nurse is caring for patient recently diagnosed and admitted with myasthenia gravis. During the morning assessment, the nurse notes some abnormal findings. Which symptom is cause for the greatest concern? a. diarrhea b. fatigue c. inability to swallow d. difficulty opening eyelids

c. inability to swallow

The nurse is planning activities for patient with myasthenia gravis. 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. medication times

A patient with Guillain-Barre' syndrome is identified as having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this patient's nutritional status? a. check skin turgor and urinary output b. give enteral feedings via feeding tube c. review weekly serum prealbumin level d. review potassium and sodium levels

c. review weekly serum prealbumin level

The patient with Guillain-Barre' syndrome is immobile and shows evidence of malnutrition. what is the priority concern related to immobility and nutritional status? a. respiratory failure b. constipation c. risk for pressure ulcers d. cardiac dysrhythmias

c. risk for pressure ulcers