Myasthenia Case Study

Which statement(s) indicates to the nurse that Shiri understands the medication teaching? "When I am nauseated, I should not take my medication." "If I miss a dose of my medication, I should double up on the next dose." "I must carry an identification card while on my medication regimen." "I need to have my serum blood levels checked monthly." "I need to try to take the medication on time."

"I must carry an identification card while on my medication regimen." "I need to try to take the medication on time."

Which statement by Shiri indicates she understands the client teaching provided by the nurse? "I can never get pregnant since I have myasthenia gravis." "I will avoid anyone that has a respiratory infection." "Relaxing in my hot tub daily will help my muscle rigidity." "I must decrease my fluid intake to 1000 mL of water a day."

"I will avoid anyone that has a respiratory infection."

Which statement indicates Shiri understands the instructions provided by the nurse? "There will be some redness and drainage at the surgical site." "I will call my healthcare provider if I have a temperature of 100.0° F or higher." "I will not lift anything that weighs more than 20 pounds." "I am glad that when I get home, I can start cooking and cleaning for my family."

"I will call my healthcare provider if I have a temperature of 100.0° F or higher."

Which statement indicates to the nurse that the medication teaching has been effective? "I am so glad that I won't have to take medications for my disease anymore." "If I have any weakness or choking episodes I will call my healthcare provider." "I will take my medication exactly as I did before I had my surgery." "I must take my medication only during times when I am stressed

"If I have any weakness or choking episodes I will call my healthcare provider."

How should the nurse respond? "This procedure will help destroy tissue in the brain so that your wife will not have the muscular weakness." "The pituitary gland will be removed by making an incision into the upper lip, and then removing the gland through the nose. This will cure her disease." "There is a gland that is usually inactive after puberty that sometimes continues to produce antibodies. Removing it sometimes cures myasthenia gravis." "This surgical procedure will remove a gland over her kidneys, which will prevent the release of a hormone that causes myasthenia gravis."

"There is a gland that is usually inactive after puberty that sometimes continues to produce antibodies. Removing it sometimes cures myasthenia gravis."

What is the best response by the nurse? "I think you should have your son talk to Shiri's healthcare provider." "A local myasthenia gravis support group may be helpful." "Would you like me to contact your Hindu spiritual advisor?" "This must be very scary, I will sit with you and we can talk for awhile."

"This must be very scary, I will sit with you and we can talk for awhile."

Which response to the test indicates that Shiri has myasthenia gravis (MG)? No significant change in Shiri's neurovascular assessment. Reduced amplitude of electrical stimulation in Shiri's muscle. Antiacetylcholine receptor antibodies present in the blood. A noticeably marked improvement in Shiri's muscle strength

A noticeably marked improvement in Shiri's muscle strength

Which action should the nurse implement first? Administer intravenous atropine. Prepare to place the client on a ventilator. Determine the reason for the overdose. Notify the admissions office.

Administer intravenous atropine.

Which action should the nurse take when they arrive? Reschedule Shiri's appointment for the next week. Allow Shiri and Alum to see the healthcare provider. Ask why they were late for the appointment. Explain that clients cannot be late for appointments.

Allow Shiri and Alum to see the healthcare provider.

Which intervention should the nurse implement prior to the plasmapheresis? Assess the complete blood cell and platelet count. Explain that the procedure will take about 1 hour. Prepare the client for the insertion of a subclavian line. Determine if the client has any allergies to iodine.

Assess the complete blood cell and platelet count.

As Shiri is completing her meal request form, the nurse considers Shiri's Hindu culture and anticipates that Shiri will select which meal? Hamburger, french fries, and iced tea. Broccoli rice casserole, salad, and water. Baked fish, white rice, and coffee. Turkey sandwich, tomato soup, and milk.

Broccoli rice casserole, salad, and water.

Which action should the nurse take? Ask the mother-in-law if Shiri could fast after she leaves the hospital. Explain that Shiri needs to eat to keep her strength. Confirm with Shiri that she needs to fast tomorrow. Notify the healthcare provider about the need for Shiri to fast.

Confirm with Shiri that she needs to fast tomorrow.

What action should the nurse implement? Reassure the couple that it is all right for her husband to touch her. Continue reviewing the discharge instructions with Shiri. Ask Alum if he is worried about touching his wife after surgery. Request that an in-home social services consultation be performed.

Continue reviewing the discharge instructions with Shiri.

Which action should the nurse take? Ask Shiri directly if she has any questions about her condition. Explain to Alum that Shiri must take an active role in her health. Continue the discussion and answer all of Alum's questions. Request that Alum leave the room so that the nurse can talk to Shiri.

Continue the discussion and answer all of Alum's questions.

Which intervention should the nurse implement? Demonstrate how to splint the incision when coughing. Explain that it may hurt but she must take deep breaths and cough. Tell Shiri not to cough and deep-breathe until the pain is gone. Notify the respiratory therapist to assist with pulmonary hygiene.

Demonstrate how to splint the incision when coughing.

Which intervention should the nurse direct toward Alum? Demonstrate how to perform abdominal thrusts correctly. Enroll the family in basic cardiopulmonary resuscitation training. Teach importance of keeping the temperature at the house above 76o F. Move the bed downstairs so Shiri will be able to rest as much as possible.

Demonstrate how to perform abdominal thrusts correctly.

Which referral to a member of the interdisciplinary team should the nurse make for Shiri? Respiratory therapist. Recreational therapist. Vocational therapist. Speech therapist.

Speech therapist.

How should the nurse respond about the expected outcome of pyridostigmine (Mestinon) therapy? Increases ability to independently perform activities of daily living (ADLs). Increases tear production for adequate moisture in the eyes. Reduces gastric acid production to aid digestion of food. Eliminates muscle pain to enhance client's ability to sleep. Prevents the breakdown of acetylcholine, a natural substance, in the body.

Increases ability to independently perform activities of daily living (ADLs). Prevents the breakdown of acetylcholine, a natural substance, in the body.

In planning care for Shiri, the nurse should identify which nursing diagnosis as a priority? Impaired swallowing. Chronic pain. Impaired skin integrity. Ineffective airway clearance.

Ineffective airway clearance.

Which intervention should the nurse implement? Instruct the client to cough and deep-breathe every shift. Notify the surgeon if there is blood in the drainage compartment. Maintain suction to ensure vigorous bubbling in the suction compartment. Monitor for fluctuation or tidaling in the water-seal compartment.

Monitor for fluctuation or tidaling in the water-seal compartment.

Which part of the assessment indicates to the nurse that Shiri is experiencing a complication from this procedure? A blood pressure of 110/70 and apical pulse of 90. Positive Chvostek's and Trousseau's signs. The serum potassium level is 4.4 mEq/L. Elevation of temperature occurs. A pulse oximeter reading of 95%.

Positive Chvostek's and Trousseau's signs. Elevation of temperature occurs

Which action should the nurse implement? Praise the UAP for making this statement while the client is eating. Explain that the UAP should not try to teach the client how to eat. Request that the UAP leave Shiri's room and go to the nurse's station. Ask the UAP where she learned how to give verbal cues for eating.

Praise the UAP for making this statement while the client is eating.

Which action should the charge nurse take? Obtain a medication occurrence report for the primary nurse to complete. Continue making rounds on the unit, ensuring that all clients are receiving safe care. Review the need for two forms of identification with the nurse at the medication cart. Immediately enter the room and teach the nurse how to correctly identify a client.

Review the need for two forms of identification with the nurse at the medication cart.

Which instruction about taking pyridostigmine (Mestinon) should the nurse include in the plan of care? Take the medication 30 minutes prior to meals. Do not eat before taking medication. Sprinkle medication on your food. Schedule daily at bedtime only.

Take the medication 30 minutes prior to meals.

Which further data indicates to the nurse the client is experiencing a cholinergic crisis? The circulating acetylcholine receptor antibodies test is positive. The symptoms improve when a cholinesterase inhibitor is administered. The blood pressure and pulse increase after a blood transfusion. The Tensilon test does not show improvement in muscle strength.

The Tensilon test does not show improvement in muscle strength.

How should the nurse respond? An increased number of acetylcholine receptor sites causes muscle weakness. A virulent virus destroys the covering of junctions between nerves and muscles. A chronic neuromuscular disorder that will eventually cause paralysis in the extremities. The body is not able to transmit nerve impulses, which results in muscle weakness.

The body is not able to transmit nerve impulses, which results in muscle weakness.