Chapter 69: Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies
A patient with Guillain-Barre' has had arterial blood gases (ABGs) drawn. Which of the following ABG values indicates that the patient's status is deteriorating? A) pH 7.37 B) PaCO2 60 C) HCO3 24 D) Oxygen saturation of 94%
B (Feedback: A PaCO2 of 60 places the patient with Guillain-Barre' in an acidotic state due to hypoventilation from respiratory muscle weakness. The pH, HCO3, and oxygen saturation are within normal levels.)
Bell's palsy is a disorder of cranial nerve VII. What are the clinical manifestations of the disorder? A) Tinnitus B) Facial paralysis C) Pain at the base of the tongue D) Diplopia
B (Feedback: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis.)
A nurse caring for a patient with possible bacterial meningitis in the ICU knows that which of the following assessment findings would be expected for a patient with bacterial meningitis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities
B (Feedback: Clinical manifestations of bacterial meningitis include positive Brudzinski's sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski's sign. Positive Homan's sign (pain upon dorsiflexion of the foot) and negative Romberg's sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the patient with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities and is not an initial assessment to rule out bacterial meningitis.)
The nurse assessing a patient with multiple sclerosis understands that due to the pathophysiology of this disease process which of the following is the expected primary finding on the MRI? A) Subarachnoid hemorrhage B) Presence of multiple plaques C) Atrophy of the caudate nuclei D) Presence of a tumor
B (Feedback: MRI is the primary diagnostic tool for visualizing plaques, documenting disease activity, and evaluating the effect of treatment. A subarachnoid hemorrhage would be seen on an MRI from a ruptured aneurysm. Atrophy of the caudate nuclei is seen in Huntington's disease. The presence of a tumor indicates brain tumor.)
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial? a) weekly visits by another person with MS b) regular exercise c) psychotherapy d) day care for the granddaughter
B (regular exercise Explanation: An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients)
A patient with trigeminal neuralgia is taking Tegretol (carbamazepine) to alleviate pain associated with this disorder. It is important to teach the patient that which of the following side effects may occur from taking this medication? A) Skin discoloration B) Drowsiness C) Insomnia D) Tinnitus
B Feedback: Side effects of Tegretol include nausea, dizziness, drowsiness, and aplastic anemia. The patient must also be monitored for bone marrow depression during long-term therapy. Skin discoloration, insomnia, and tinnitus are not side effects of Tegretol.
The nurse knows that plasmapheresis is being utilized in the treatment of the patient with Guillain-Barre' syndrome for which of the following reasons? A) Removal of anti-acetylcholine receptor antibodies B) Reduction in the number of bacteria in the bloodstream C) Decrease in antibodies attacking peripheral nerve myelin D) Removal of potassium and fluid
C (Chapter: 64 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing Process Objective: 2 Patient Needs: A-1 Feedback: Plasmapheresis and IV immunoglobulin (IVIG) are used to directly affect the peripheral nerve myelin antibody level. Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. In myasthenia gravis, plasmapheresis is used to remove anti-acetylcholine receptor antibodies. Antibiotics reduce the number of bacteria in the bloodstream. Hemodialysis removes fluid and potassium.)
Which of the following clinical manifestations would alert the nurse caring for a patient with Guillain-Barré syndrome that his status is deteriorating? A) Tidal volume of 500 mL B) Residual lung volume of 1200 mL C) Vital capacity of 11 mL/kg D) Oxygen saturation of 97%
C (Feedback: A vital capacity of 12 to 15 mL/kg in a patient with Guillain-Barre' means that the patient's condition has deteriorated to the point that he may need to be mechanically ventilated. Thus, a vital capacity of 11 mL/kg is a warning. The tidal volume, residual lung volume, and oxygen saturation are within normal values. Breathing in a Guillain Barre' patient would become increasingly labored as the paralysis ascended toward the intercostals and diaphragm.)
Which of the following is a clinical manifestation associated with Guillain-Barré syndrome? A) Vertigo B) Ptosis of the eyelid C) Diminished taste for food D) Vocal paralysis
D (Feedback: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness).)
The nurse would expect to document which of the following in a patient with myasthenia gravis undergoing a Tensilon test? A) Positive Tensilon test B) Negative Tensilon test C) Positive sweat test D) Negative sweat test
A (Feedback: The patient in myasthenic crisis improves immediately following administration of edrophonium chloride (Tensilon). Sweat tests are used in diagnosing cystic fibrosis, not myasthenia gravis.)
The physician has ordered a Tensilon test to rule out myasthenia gravis. The nurse knows that which of the following medications would be used to counteract the side effects of the Tensilon? A) Baclofen (Lioresal) B) Atropine (AtroPen) C) Epinephrine (Adrenalin) D) Narcan (Naloxone)
B (Feedback: Atropine 0.4 mg controls the side effects of Tensilon, which include bradycardia, sweating, and cramping. Baclofen is a skeletal muscle relaxant used in the treatment of multiple sclerosis. Epinephrine is used in the treatment of anaphylaxis, cardiac arrest, and bronchospasm. Narcan is used to reverse the narcotic-induced respiratory depression.)
Which of the following schedules would be most appropriate for the care of a 28-year-old female hospitalized with a diagnosis of myasthenia gravis? A) All at one time, to provide a longer rest period B) Before meals, to stimulate her appetite C) In the morning, with frequent rest periods D) Before bedtime, to promote rest
C (Feedback: Myasthenia gravis is characterized by extreme muscle weakness, which generally worsens after effort and improves with rest. The schedule for procedures should be spaced to allow for rest in between. Procedures should be avoided before meals, or the patient may be too exhausted to eat. Procedures should also be avoided at bedtime.)
A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinski's reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
C (Feedback: Optic neuritis, leading to blurred vision, is a common early sign of MS, as is intention tremor (tremor when performing an activity). Nerve damage can cause urinary hesitancy. In MS, deep tendon reflexes are increased or hyperactive. A positive Babinski's reflex is found in MS. Abdominal reflexes are absent with MS.)
The nurse recognizes that corticosteroid therapy, when used in the treatment of Guillain-Barre' syndrome, reduces the inflammation and edema associated with this neuromuscular disorder. It is most important for the nurse to monitor which of the following lab values for the patient on corticosteroid therapy? A) pH of urine B) Hemoglobin C) Serum potassium D) Serum glucose
D (Feedback: Corticosteroid therapy increases the blood glucose level. Corticosteroids have an effect on insulin and can produce symptoms related to glucose intolerance.)
A client with Parkinson's disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy? a) alertness b) appetite c) mood d) muscle rigidity
D (muscle rigidity Explanation: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson's disease.)
A client arrives at the emergency department complaining of extreme muscle weakness after minimal effort. The physician suspects myasthenia gravis. Which drug will be used to test for this disease? a) Edrophonium b) Carbachol c) Pyridostigmine d) Ambenonium
A (Edrophonium Explanation: Edrophonium temporarily blocks the breakdown of acetylcholine, thus increasing acetylcholine level in the blood, and relieves weakness. Because of its short duration of action, edrophonium is the drug of choice for diagnosing myasthenia gravis. It's also used to differentiate myasthenia gravis from cholinergic toxicity. Ambenonium is used as an antimyasthenic. Pyridostigmine serves primarily as an adjunct in treating severe anticholinergic toxicity; it's also an antiglaucoma agent and a miotic. Carbachol reduces intraocular pressure during ophthalmologic procedures; topical carbachol is used to treat open-angle and closed-angle glaucoma)
An expected nursing intervention for a patient diagnosed with Bell's palsy would be which of the following? A) Applying a protective eye shield B) Encouraging the patient to eat on the affected side C) Avoiding analgesics D) Avoiding brushing of the teeth
A (Feedback: Corneal irritation and ulceration may occur if the eye is unprotected. While paralysis lasts, the involved eye must be protected. The patient is encouraged to eat on the unaffected side, due to swallowing difficulties. Analgesics are used to control the facial pain. The patient should continue to provide self-care including oral hygiene.)
When teaching a client about levodopa-carbidopa therapy for Parkinson's disease, a nurse should include which instruction? a) "Report any eye spasms." b) "Be aware that your urine may appear darker than usual." c) "Stop taking this drug when your symptoms disappear." d) "Take this medication at bedtime."
B ("Be aware that your urine may appear darker than usual." Explanation: Levodopa-carbidopa, used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life.)
A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? a) "My family will take care of me. I've given my daughter durable power of attorney for health care." b) "I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." c) "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes." d) "I know that I'll eventually be unable to make decisions. Signing an advance directive now will save my family grief."
B ("I don't really need to sign anything. I'm depending on my physician to tell my family what to do if something bad happens." Explanation: The client requires additional teaching if the client states that he/she will depend on the physician to tell the family what to do in regards to his/her health. The client should not rely on the physician to tell the family what to do. The best way for the client to convey his/her health care wishes is to put them in writing in an advance directive. The client stating that he/she has designated his/her daughter to make health care decisions when the client cannot, that the client has signed an advance directive, or that the client knows an advance directive will help when he/she is unable to make decisions indicate that the client has made decisions about his/her end-of-life care.)
It is important to frequently monitor the patient with Guillain-Barre' syndrome when ascending paralysis is occurring. When assessing the patient for bulbar muscle weakness, the nurse should be alert to which of the following clinical manifestations? A) Decreased level of consciousness B) Inability to clear secretions C) Hypersensitivity of hands and feet D) Increased intracranial pressure
B (Feedback: Bulbar muscle weakness related to demyelinization of the glossopharyngeal and vagus nerves results in an inability to swallow or clear secretions. Guillain-Barre' does not affect cognitive function or level of consciousness. Sensory symptoms include paresthesias of the hands and feet related to demyelinization of the sensory fibers. Guillain-Barre' does not cause increased intracranial pressure.)
When teaching the patient with multiple sclerosis how to reduce fatigue, the nurse should tell him to: A) Take a hot bath. B) Rest in an air-conditioned room. C) Increase the dose of muscle relaxants. D) Avoid naps during the day.
B (Feedback: Fatigue is a common symptom in patients with multiple sclerosis. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the patient with multiple sclerosis include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity.)
A 42-year-old woman diagnosed with metastatic cancer has developed trigeminal neuralgia. She is taking carbamazepine (Tegretol) for pain relief. Which of the following applies to this medication? A) The medication should be taken on an empty stomach. B) Thee patient should be monitored for bone marrow depression.. C) Side effects include renal dysfunction. D) The medication should be taken in maximum dosage form to be effective.
B (Feedback: The anticonvulsant agents carbamazepine (Tegretol) and phenytoin (Dilantin) relieve pain in most patients diagnosed with trigeminal neuralgia by reducing the transmission of impulses at certain nerve terminals. Carbamazepine is taken with meals and should be gradually increased until pain relief is obtained.)
Which is an expected outcome for a client with Parkinson's disease who has had a pallidotomy? a) reduced emotional stress b) improved functional ability c) better appetite d) increased alertness
B (improved functional ability Explanation: The goal of a pallidotomy is to improve functional ability for the client with Parkinson's disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidotomy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite.)
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) increase the dose of muscle relaxants. b) take a hot bath. c) rest in an air-conditioned room. d) avoid naps during the day.
C (rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity)
Which of the following primary manifestations is the nurse most likely to assess in a patient diagnosed with MS? A) Dementia B) Bradykinesia C) Contracture deformities D) Difficulty in coordination
D (Feedback: The primary symptoms most commonly reported with patients who have MS are difficulties with coordination, spasticity of the extremities, and loss of coordination. Secondary symptoms of MS include contracture deformities and rarely dementia.)
When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis? a) Increased weakness. b) Diaphoresis. c) Increased salivation. d) Improved muscle strength after I.V. administration of edrophonium chloride.
D (Improved muscle strength after I.V. administration of edrophonium chloride. Explanation: Extreme muscle weakness is present in both cholinergic crisis and myasthenic crisis. In cholinergic crisis, I.V. edrophonium chloride, a cholinergic agent, does not improve muscle weakness; in myasthenic crisis, it does. Diaphoresis and increased salivation are not present in cholinergic crises.)
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Respiratory acidosis
D (Respiratory acidosis Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.)
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. The nurse should: a) give the client a muscle relaxant. b) have the UAP keep a steady pull on the client to promote forward ambulation. c) assist the UAP with getting the client back in bed. d) explain how to overcome a freezing gait by telling the client to march in place.
D (explain how to overcome a freezing gait by telling the client to march in place. Explanation: Clients with Parkinson's disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep them on bed rest. A muscle relaxant is not indicated.)
The primary nursing goal for a client with myasthenia gravis is to: a) provide psychological support and reassurance. b) promote comfort and relieve pain. c) ensure a safe environment. d) maintain respiratory function.
D (maintain respiratory function. Explanation: In myasthenia gravis, major respiratory complications can result from weakness in the muscles of breathing and swallowing. The client is at risk for aspiration, respiratory infection, and respiratory failure. Providing a safe environment and emotional support are secondary goals. Pain is not commonly associated as a problem of myasthenia gravis.)
Which goal is the most realistic for a client diagnosed with Parkinson's disease? a) to cure the disease b) to begin preparations for terminal care c) to stop progression of the disease d) to maintain optimal body function
D (to maintain optimal body function Explanation: Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease: and it would not be appropriate to start planning terminal care at this time)
A client has an exacerbation of multiple sclerosis. The physician orders dantrolene, 25 mg P.O. daily. Which assessment finding indicates the medication is effective? a) Increased ability to sleep b) Relief from pain c) Relief from constipation d) Reduced muscle spasticity
d (Reduced muscle spasticity Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain.)
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? a) Establish a regular voiding schedule. b) Insert an indwelling urinary catheter. c) Limit fluid intake to 1,000 mL/day. d) Administer prophylactic antibiotics, as prescribed.
A (Establish a regular voiding schedule. Explanation: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.)
When developing a plan of care for a patient with Guillain-Barre' syndrome, the nurse knows that which of the following nursing interventions would receive priority? A) Using the incentive spirometer as prescribed B) Maintaining the patient on bed rest C) Assisting the patient with activities of daily living D) Determining abnormalities of cognitive function
A (Feedback: Impaired gas exchange would be the priority. Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions aimed at enhancing physical mobility and preventing a deep vein thrombosis are utilized. Assisting the patient with activities of daily living is important but would not be the priority nursing intervention. Guillain-Barre' does not affect cognitive function or level of consciousness.)
What basic information will the nurse caring for a patient recently diagnosed with multiple sclerosis (MS) provide to him? A) It is a degenerative disease of the nervous system. B) It usually occurs more frequently in men. C) It has an acute onset. D) It is caused by a bacterial infection.
A (Feedback: Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system (CNS) characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known; it affects twice as many women as men.)
When assessing a patient with myasthenia gravis, the nurse would be correct in questioning the patient regarding which of the following clinical manifestations? A) Weakness associated with fatigue B) Headache that worsens at night C) Projectile vomiting without nausea D) Diaphoresis
A (Feedback: Myasthenia gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Generalized weakness affects all the extremities and the intercostal muscles, resulting in varying decreasing vital capacity and respiratory failure. The other manifestations listed are not symptomatic of myasthenia gravis.)
When examining a patient with Guillain-Barre' syndrome, the nurse would expect to assess which of the following clinical manifestations? A) Paresthesias of the hands and feet B) Hyperactive deep tendon reflexes C) Hypotension D) Descending weakness
A (Feedback: Sensory symptoms of Guillain-Barre' include paresthesias of the hands and feet, and pain related to the demyelinization of sensory fibers. Other clinical manifestations include hyporeflexia and loss of deep tendon reflexes. A classic feature of Guillain-Barre' is ascending weakness.)
The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis? A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles
A (Feedback: Vision changes, such as diplopia, nystagmus, and blurred vision are symptoms of multiple sclerosis. Deep tendon reflexes may be increased or hyperactive, not absent. Babinski's sign may be positive. Tremors at rest aren't characteristic of multiple sclerosis; however, intentional tremors, or those occurring with purposeful voluntary movement, are common in patients with multiple sclerosis. Affected muscles are spastic rather than flaccid.)
The nurse teaching a patient with trigeminal neuralgia about factors that precipitate an attack would be correct in teaching him to avoid: A) Washing his face B) Exposing his skin to sunlight C) Using artificial tears D) Drinking liquids at room temperature
A (Feedback: Washing the face should be avoided if possible due to the fact that this activity can trigger an attack of pain in a patient with trigeminal neuralgia. Exposing the skin to sunlight is not harmful to this patient. Using artificial tears and drinking liquids at room temperature are appropriate behaviors.)
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) limiting fluid intake to 1,000 mL/day b) setting a regular time for elimination c) using an elevated toilet seat d) eating a diet high in fiber
A (Limiting fluid intake to 1,000 mL/day Explanation: Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.)
What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking b) Muscle pain, difficulty speaking, headaches, and arthritic changes c) Muscle inflammation, choking when eating, nearsightedness, and painful joints d) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving
A (Muscle weakness, difficulty swallowing, double vision, and difficulty speaking Explanation: With myasthenia gravis there is a disturbance in nerve transmission to the muscles. The signs and symptoms in this answer reflect this neuromuscular impairment. The other answers include signs and symptoms not related to neuromuscular impairment, such as atrophy, muscle inflammation, headaches, and arthritic changes.)
Which is an initial sign of Parkinson's disease? a) tremor b) bradykinesia c) rigidity d) akinesia
A (Tremor Explanation: The first sign of Parkinson's disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradykinesia is the third sign. Akinesia is a later stage of bradykinesia.)
The nurse assesses for euphoria in a client with multiple sclerosis, looking for what characteristic clinical manifestation? a) an exaggerated sense of well-being b) slurring of words when excited c) visual hallucinations d) inappropriate laughter
A (an exaggerated sense of well-being Explanation: A client with multiple sclerosis may have a sense of optimism and euphoria, particularly during remissions. Euphoria is characterized by mood elevation with an exaggerated sense of well-being. Inappropriate laughter, slurring of words, and visual hallucinations are uncharacteristic of euphoria.)
Upon admission, the physician orders baclofen (Lioresal) for a patient diagnosed with multiple sclerosis. The nurse knows that which of the following is an expected outcome of this medication? A) Reduction in the appearance of new lesions on the MRI B) Decreased muscle spasms in the lower extremities C) Increased muscle strength in the upper extremities D) Limited severity and duration of exacerbations
B (Feedback: Baclofen, a GABA agonist, is the medication of choice in treating spasms. It can be administered orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Anticholinesterase agents increase muscle strength in the upper extremities. Corticosteroids limit the severity and duration of exacerbations.)
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the client to prevent: a) fluid overload. b) contractures. c) dry mouth. d) ascites.
B (contractures. Explanation: Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory infections. Nursing care should be directed toward the goal of preventing these complications. Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.)
Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis? a) Imbalanced nutrition: less than body requirements b) Impaired urinary elimination c) Ineffective airway clearance d) Risk for injury
C (Ineffective airway clearance Explanation: In parkinsonian crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of an ineffective airway clearance takes the highest priority. Although imbalanced nutrition: less than body requirements, impaired urinary elimination, and risk for injury are also appropriate nursing diagnoses, they are not immediately life-threatening.)
Which of the following nursing interventions would be included in the care plan for a patient admitted with MS? A) Encourage the patient to void 1 hour after drinking. B) Order a low-residue diet. C) Provide total assistance as needed with all activities of daily living. D) Instruct the patient on daily muscle stretching.
D (Feedback: A patient diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The patient should participate in daily muscle stretching to help alleviate and relax muscle spasms.)
The nurse is caring for a patient recently diagnosed with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment data would be consistent with the diagnosis of myasthenia gravis? A) Decreased sensation in the hands and feet B) Incoordination of gait C) Facial numbness causing slurred speech D) Generalized weakness of the extremities
D (Feedback: Generalized weakness affects all the extremities and the intercostal muscles, resulting in decreasing vital capacity and respiratory failure in the myasthenia gravis patient. Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination.)
The nurse teaching a patient recently diagnosed with myasthenia gravis should tell him that it is caused by: A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion
D (Feedback: Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It isn't a genetic disorder. Combined upper and lower neuron lesions generally occur as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord causes decreased conduction of impulses at an upper motor neuron._)
The nurse is caring for a recently diagnosed patient with myasthenia gravis whose CT scan reveals an enlarged thymus gland. Which additional assessment parameter should the nurse complete to confirm the diagnosis of myasthenia gravis? A) Passive range of motion of the neck B) Check of deep tendon reflexes C) Application of painful stimuli to legs D) Visual screening using the Snellen chart
D (Feedback: Patients with myasthenia gravis commonly exhibit diplopia (double vision) and ptosis. Using the Snellen chart enables the nurse to assess both of these clinical manifestations. Performing passive range of motion on the neck indicates whether or not the patient has nuchal rigidity, which is a clinical manifestation of meningitis, not myasthenia gravis. Checking deep tendon reflexes is not specific to myasthenia gravis. Application of painful stimuli assesses level of consciousness but also is not specific to myasthenia gravis.)
