HESI Case Studies--Medical/Surgical-Myasthenia Gravis (Shiri Koradia)

4. How should the nurse respond about the expected outcome of pyridostigmine (Mestinon) therapy?(Select all)

-Increases the ability to independently perform activities of daily living (ADLs) [This medication promotes muscle contraction, improving muscle strength and allowing the client to perform ADLs without assistance.] -Prevents the breakdown of acetylcholine, a natural substance, in the body [Acetylcholine is needed for normal muscle function.]

18. Which part of the assessment indicates to the nurse that Shiri is experiencing a complication from this procedure? (Select all)

-Positive Chvostek's and Trousseau's signs [These positive signs indicate hypocalcemia which is a complication of plasmapheresis that occurs when the anticoagulant citrate dextrose binds with calcium.] -Elevation of temperature occurs [Complications from plasmapharesis may include fever, rash and wheezing]

20. Which intervention should the nurse implement?

Demonstrate how to splint the incision when coughing [The thoractomy and chest incision will cause pain when the client is coughing. The nurse should demonstrate how to splint the incision to help the pain. Pulmonary hygiene must be a priority to prevent pulmonary complications of atelectasis and pneumonia.]

7. Which intervention should the nurse direct toward Alum?

Demonstrate how to perform abdominal thrusts correctly [Shiri is at risk for choking, and knowing specific measures to help her during choking episodes is a priority. Remember, airway is priority.]

11. In planning care for Shiri, the nurse should identify which diagnosis as a priority?

Ineffective airway clearance [The body's inability to contract muscles effectively results in a poor cough mechanism, decreased rib expansion, diminished diaphragmatic movement, and decreased expiratory effort. Therefore, ineffective airway clearance is the priority client problem.]

19. Which intervention should the nurse implement?

Monitor for fluctuation or tidaling in the water-seal compartment [Fluctuation or tidaling indicates air is being removed from the pleural space.]

22. Which action should the nurse implement?

Praise the UAP for making this statement while the client is eating [Using small bites of food and chewing thoroughly may help prevent aspiration; therefore, the nurse should praise the UAP for reinforcing the correct dysphagia precautions.]

23. Which action should the charge nurse take?

Review the need for two form of identification with the nurse at the medication cart [The Joint Commission's National Patient Safety Goals requires that two forms of identification be used when medication or blood products are administered. These may include the client's name, along with the hospital identification number on the arm band, or the client's date of birth. The charge nurse should take action as soon as the primary nurse leaves the client's room to prevent a recurrence of the action with another client.]

5. Which instruction about taking pyridostigmine (Mestinon) should the nurse include in the plan of care?

Take the medication 30 minutes prior to meals [This medication will increase muscle strength to help enhance swallowing and chewing during meals, and it will increase strength prior to activities such as brushing hair, brushing teeth, or putting on make-up.]

10. Which further data indicates to the nurse the client is experiencing a cholinergic crisis

The Tensilon test does not show improvement in muscle strength [The Tensilon test not only diagnoses MG, but it also helps determine which type of crisis the client is experiencing. In a myasthenia crisis, the test is positive (the client's muscle strength improves), and in a cholinergic crisis, the test is negative (there is no improvement in muscle strength).]

8. Which statement by Shiri indicates she understands the client teaching provided by the nurse?

"I will avoid anyone that has a respiratory infection." [Infections can result in an exacerbation of MG and can cause extreme weakness. In addition, the client with MG should increase fluid intake to help mobilize and expectorate sputum to aid in the prevention of respiratory complications]

25. Which statement indicates Shiri understands the instructions provided by the nurse?

"I will call my healthcare provider if I have a temperature of 100.0F or higher." [Any elevation in temperature that is greater than 100.0° F indicates an infection, which may be respiratory, systemic, or incisional and should be reported to the healthcare provider.]

26. Which statement indicates to the nurse that the medication teaching has been effective?

"If I have any weakness or choking episodes I will call my healthcare provider." [Approximately 50% of clients with MG go into total remission after a thymectomy. However, if symptoms reoccur, the client may have to be placed on medications again.]

16. How should the nurse respond?

"There is a gland that is usually inactive after puberty that sometimes continues to produce antibodies. Removing it sometimes cures myasthenia gravis." [In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies that trigger an autoimmune response in MG. A thymectomy, the removal of the thymus gland, cures myasthenia gravis in about 50% of the clients.]

13. What is the best response by the nurse?

"This must be very scary, I will sit with you and we can talk for a while." [Acknowledgement of the mother-in-law's feelings and therapeutic use of self provide the opportunity for the mother-in-law to verbalize her fears and concerns. The nurse may later choose to encourage further communication with the healthcare provider, offer information about support groups, or offer to contact a spiritual advisor.]

6. Which statement(s) indicates to the nurse that Shiri understands the medication teaching? (Select all)

-"I must carry an identification card while on my medication regimen." [The client should carry identification describing the disease and the medication regimen at all times. Any emergency personnel or other healthcare providers should be aware of the client's disease process.] -"I need to try to take the medication on time." [Since the medication peaks in 2 hours and the duration of effect is 3-6 hours, doses need to be timed to prevent a return of muscle weakness symptoms.]

1. Which response to the test indicates that Shiri has myasthenia gravis (MG)?

A noticeably marked improvement in Shiri's muscle strength [Clients with MG show a significant improvement in muscle strength that lasts approximately 5 minutes when Tensilon is injected. This test confirms the diagnosis.]

12. Which action should the nurse implement first?

Administer intravenous atropine [Atropine is the antidote for a cholinergic crisis and should be administered as soon as it is determined that the client is in a cholinergic crisis rather than a myasthenia crisis.]

15. Which action should the nurse take when they arrive?

Allow Shiri and Alum to see the healthcare provider [Punctuality in keeping scheduled appointments is not considered important in the Hindu culture. The nurse should not misconstrue being late for appointments as a sign of irresponsibility or not valuing health.]

17. Which intervention should the nurse implement prior to the plasmapheresis?

Assess the complete blood cell and platelet count [These lab values should be assessed because clients undergoing plasmapheresis are at high risk for anemia and coagulation problems secondary to hemolysis of cells.]

21. As Shiri is completing her meal request form, the nurse considers Shiri's Hindu culture and anticipates that Shiri will select which meal?

Broccoli rice casserole, salad, and water [Although some Hindus eat meat, the majority of Hindu people are strict vegetarians, and water is the beverage of choice. The nurse would expect that Shiri is a vegetarian until stated otherwise.]

14. Which action should the nurse take?

Confirm with Shiri that she needs to fast tomorrow [The nurse should support Shiri's religious beliefs if at all possible. Hindu women often fast 1 day a week to fulfill a vow made to a deity in supplication for a particular blessing. Wives frequently fast to secure the continued health of their husbands and family.]

24. What action shuold the nurse implement?

Continue reviewing the discharge instructions with Shiri [In the Hindu culture, touching and embracing in public are not acceptable displays of affection, even between spouses. A public display of affection such as hugging or kissing is frowned upon and is considered strictly a private matter.]

3. Which action should the nurse take?

Continue the discussion and answer all of Alum's questions [In the Hindu culture, women are expected to strictly follow deference customs, which includes avoiding direct eye contact with men. Direct eye contact with elders and authority figures is considered a sign of disrespect.]

9. Which referral to a member of the interdisciplinary team should the nurse make for Shiri?

Speech therapist [A speech therapist addresses swallowing problems. Clients with MG are dysphagic and are at risk for aspiration. The speech therapist can help match food consistency to the client's ability to swallow, which helps enhance client safety.]

2. How should the nurse respond?

The body is not able to transmit nerve impulses, which results in muscle weakness [In MG, antibodies destroy or block neuromuscular junction receptor sites, resulting in a decreased number of acetylcholine receptors. This results in a decrease in the muscle's ability to transmit nerve impulses and contract.]