MS3, Exam 3, Ch. 58: - ALS (Lou Gehrig's), myasthenia gravis, Huntington's disease (chorea),

Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching? 1. "I will not have any menstrual cycles because of this disease." 2. "I should avoid people who have respiratory infections." 3. "I should not take a hot bath or swim in cold water." 4. "I will drink at least 2,500 mL of water a day."

1. "I will not have any menstrual cycles because of this disease." MG has no effect on the ovarian function and the uterus is an involuntary muscle, not a skeletal muscle, so the menstrual cycle is not affected.

The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding? 1. A residual of 125 mL. 2. The abdomen is soft. 3. Three episodes of diarrhea. 4. The potassium level is 3.4 mEq/L.

1. A residual of 125 mL. A residual (aspirated gastric contents) of greater than 50 to 100 mL indicates that the tube feeding is not being digested and that the feeding should be held.

The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Administer the medication 30 minutes prior to meals. 2. Instruct the client to take with eight (8) ounces of water. 3. Explain the importance of sitting up for one (1) hour after taking medication. 4. Assess the client's blood pressure prior to administering medication.

1. Administer the medication 30 minutes prior to meals. This medication will increase muscle strength to help enhance swallowing and chewing during meals.

The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? Select all that apply. 1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 3. Assess the client's pulse oximeter reading every shift. 4. Plan meals to promote medication effectiveness. 5. Monitor the client's serum anticholinesterase levels.

1. Assist the client to turn and cough every two (2) hours. 2. Place the client in a high or semi-Fowler's position. 4. Plan meals to promote medication effectiveness. Position changes promote lung expansion, and coughing helps clear secretions from the tracheobronchial tree. This position expands the lungs and alleviates pressure from the diaphragm. The medications should be administered 30 4-minutes before the meal to provide optimal muscle strength for swallowing and chewing.

The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? 1. Discuss ways to help prevent choking episodes. 2. Explain how to care for a client on a ventilator. 3. Teach how to perform passive range-of-motion exercises. 4. Demonstrate how to care for the client's feeding tube.

1. Discuss ways to help prevent choking episodes. The client is at risk for choking; knowing specific measures to help the client helps decrease the client's, as well as the significant other's, anxiety and promotes confidence in managing potential complications.

The client is diagnosed with ALS. Which client problem would be most appropriate for this client? 1. Disuse syndrome. 2. Altered body image. 3. Fluid and electrolyte imbalance. 4. Alteration in pain.

1. Disuse syndrome. Disuse syndrome is associated with complications of bedrest. Clients with ALS cannot move and reposition themselves, and they frequently have altered nutritional and hydration status.

The client is in the terminal stage of ALS. Which intervention should the nurse implement? 1. Perform passive ROM every two (2) hours. 2. Maintain a negative nitrogen balance. 3. Encourage a low-protein, soft-mechanical diet. 4. Turn the client and have him cough and deep breathe every shift.

1. Perform passive ROM every two (2) hours. Contractures can develop within a week because extensor muscles are weaker than flexor muscles. If the client cannot perform ROM exercises, then the nurse must do it for him—passive ROM.

The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply. 1. Refer to the Huntington's Chorea Foundation. 2. Explain the need for the client to wear football padding. 3. Discuss how to cope with the client's messiness. 4. Provide three (3) meals a day and no between-meal snacks. 5. Teach the family how to perform chest percussion.

1. Refer to the Huntington's Chorea Foundation. 2. Explain the need for the client to wear football padding. 3. Discuss how to cope with the client's messiness. Foundations offer the family and client information about the disease, support groups, and up-to-date information on current research. The use of padding will help prevent injury from the constant movement that occurs with this disease. The constant movement causes the client to be messy when eating, dressing, or performing activities of daily living.

The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective? 1. The client is able to feed self independently. 2. The client is able to blink the eyes without tearing. 3. The client denies any nausea or vomiting when eating. 4. The client denies any pain when performing ROM exercises.

1. The client is able to feed self independently. This medication promotes muscle contraction, which improves muscle strength, which, in turn, allows the client to perform ADLs without assistance.

The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention? 1. The client's BP is 94/60 and AP is 112. 2. Negative Chvostek's and Trousseau's signs. 3. The serum potassium level is 3.5 mEq/L. 4. Ecchymosis at the vascular site access.

1. The client's BP is 94/60 and AP is 112. Hypovolemia is a complication of plasmapheresis, especially during the procedure, when up to 15% of the blood volume is in the cell separator.

The client diagnosed with ALS asks the nurse, "I know this disease is going to kill me. What will happen to me in the end?" Which statement by the nurse would be most appropriate? 1. "You are afraid of how you will die?" 2. "Most people with ALS die of respiratory failure." 3. "Don't talk like that. You have to stay positive." 4. "ALS is not a killer. You can live a long life."

2. "Most people with ALS die of respiratory failure." About 50% of clients die within two (2) to five (5) years from respiratory failure, aspiration pneumonia, or another infectious process.

The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first? 1. Elevate the head of the bed 30 degrees. 2. Administer oxygen via nasal cannula. 3. Assess the client's lung sounds. 4. Obtain a pulse oximeter reading.

2. Administer oxygen via nasal cannula. Oxygen should be given immediately to help alleviate the difficulty breathing. Remember that oxygenation is a priority.

Which diagnostic test is used to confirm the diagnosis of Amyotropic Lateral Sclerosis (ALS)? 1. Electromyogram (EMG). 2. Muscle biopsy. 3. Serum creatine kinase (CK). 4. Pulmonary function test.

2. Muscle biopsy. Biopsy confirms changes consistent with atrophy and loss of muscle fiber, both characteristic of ALS.

Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? 1. Weakness and fatigue. 2. Ptosis and diplopia. 3. Breathlessness and dyspnea. 4. Weight loss and dehydration.

2. Ptosis and diplopia. These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral blurred vision.

The son of a client diagnosed with ALS asks the nurse, "Is there any chance that I could get this disease?" Which statement by the nurse would be most appropriate? 1. "It must be scary to think you might get this disease." 2. "No, this disease is not genetic or contagious." 3. "ALS does have a genetic factor and runs in families." 4. "If you are exposed to the same virus, you may get the disease."

3. "ALS does have a genetic factor and runs in families." There is a genetic factor with ALS that is linked to a chromosome 21 defect.

Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the s/s of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.

3. A thymectomy. In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies, triggering an autoimmune response in MG. After a thymectomy, the production of autoantibodies is reduced or eliminated, and this may resolve the signs/symptoms of MG.

The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement? 1. Discuss the need to be placed in a long-term care facility. 2. Explain how to care for a sigmoid colostomy. 3. Assist the client to prepare an advance directive. 4. Teach the client how to use a motorized wheelchair.

3. Assist the client to prepare an advance directive. A client with ALS usually dies within five (5) years. Therefore, the nurse should offer the client the opportunity to determine how he/she wants to die.

The nurse is caring for several clients on a medical unit. Which client should the nurse assess first? 1. The client with ALS who is refusing to turn every two (2) hours. 2. The client with abdominal pain who is complaining of nausea. 3. The client with pneumonia who has a pulse oximeter reading of 90%. 4. The client who is complaining about not receiving any pain medication.

3. The client with pneumonia who has a pulse oximeter reading of 90%. A pulse oximeter reading of less than 93% indicates that the client is experiencing hypoxemia, which is a life-threatening emergency. This client should be assessed first.

The nurse has received the morning report and has the following medications due or being requested. In which order should the nurse administer the medications? List in order of priority. 1. Administer furosemide (Lasix), a loop diuretic, IVP daily to a client diagnosed with heart failure who is dyspneic on exertion. 2. Administer morphine, a narcotic analgesic, IVP prn to a client diagnosed with lower back pain who is complaining of pain at a "10" on a 1-to-10 scale. 3. Administer neostigmine (Prostigmin), a cholinesterase inhibitor, PO to a client diagnosed with myasthenia gravis. 4. Administer lidocaine, an antidysrhythmic, IVP prn to a client in normal sinus rhythm with multifocal premature ventricular contractions. 5. Administer vancomycin, an aminoglycoside antibiotic, to a client diagnosed with a Staphylococcus infection who has a trough level of 14 mg/dL.

4, 3, 2, 1, 5 4. Although the lidocaine is a prn order, this client is exhibiting a life-threatening dysrhythmia, multifocal premature ventricular contractions. 3. The client diagnosed with myasthenia gravis must have this medication as close to the specific time as possible. This medication allows skeletal muscle to function; if this medication is delayed, the client may experience respiratory distress. 2. Pain is a priority and should be attended to after administering medications to clients in life-threatening situations. 1. This client is symptomatic, and the loop diuretic should relieve some of the symptoms of dyspnea. 5. Intravenous antibiotics are priority, but this client has received several doses of the medication or there would not be a trough level, so this client's medication could wait until the other medications have been administered.

The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement? 1. Refer the child for genetic counseling as soon as possible. 2. Teach the child to use a warming tray under the food during meals. 3. Discuss the importance of not abandoning the parent. 4. Allow the child to talk about the fear of getting the disease.

4. Allow the child to talk about the fear of getting the disease. The child will develop this disease if he or she inherited the gene. It can be frightening for children to watch a parent progress through this disease and understand that they too may get it.

The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client? 1. Take the medication with food. 2. Do not eat green, leafy vegetables. 3. Use SPF 30 when going out in the sun. 4. Report any febrile illness.

4. Report any febrile illness. The medication can cause blood dyscrasias. Therefore, the client is monitored for liver function, blood count, blood chemistries, and alkaline phosphatase. The client should report any febrile illness. This is the first medication developed to treat ALS.

The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse? 1. Discuss the Myasthenia Foundation with the client's wife. 2. Refer the client to a local myasthenia gravis support group. 3. Ask the client's wife if she would like to talk to a counselor. 4. Sit down and allow the wife to ventilate her feelings to the nurse.

4. Sit down and allow the wife to ventilate her feelings to the nurse. Directly addressing the wife's feelings is the best action for the nurse in this situation. All the other options can be done, but the best action is to address the wife's feelings.

Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis? 1. Occupational therapist. 2. Recreational therapist. 3. Vocational therapist. 4. Speech therapist.

4. Speech therapist. Speech therapists address swallowing problems, and clients with MG are dysphagic and at risk for aspiration. The speech therapist can help match food consistency to the client's ability to swallow, which enhances client safety.

The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after IV fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.

4. The Tensilon test does not show improvement in the client's muscle strength. The injection of edrophonium chloride (Tensilon test) not only diagnoses MG but helps to determine which type of crisis the client is experiencing. In a myasthenic crisis, the test is positive (the client's muscle strength improves), but in cholinergic crisis, the test is negative (there is no improvement in muscle strength), or the client will actually get worse and emergency equipment must be available.

The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is increased amplitude of electrical stimulation in the muscle. 3. The circulating acetylcholine receptor antibodies are decreased. 4. The client shows a marked improvement of muscle strength.

4. The client shows a marked improvement of muscle strength. Clients with MG show a significant improvement of muscle strength lasting approximately five (5) minutes when Tensilon (edrophonium chloride) is injected.

The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis? 1. Muscle atrophy and flaccidity. 2. Fatigue and malnutrition. 3. Slurred speech and dysphagia. 4. Weakness and paralysis.

4. Weakness and paralysis. ALS results from the degeneration and demyelination of motor neurons in the spinal cord, which results in paralysis and weakness of the muscles.