Multiple Sclerosis, Myasthenia Gravis, GBS
11. The nurse writes the client problem of "altered sexual functioning" for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented? 1. Encourage the couple to explore alternative ways of maintaining intimacy. 2. Make an appointment with a psychotherapist to counsel the couple. 3. Explain daily exercise will help increase libido and sexual arousal. 4. Discuss the importance of keeping physically calm during sexual intercourse.
11. 1. This will assist the client and significant other to maintain a close relationship without putting undue pressure on the client.
12. The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? Select all that apply. 1. Muscle flaccidity. 2. Lethargy. 3. Dysmetria. 4. Fatigue. 5. Dysphagia.
12. 1. Muscle flaccidity is a hallmark symptom of MS. 3. Dysmetria is the inability to control muscular action characterized by overestimating or underestimating range of movement. 4. Fatigue is a symptom of MS. 5. Dysphagia, or difficulty swallowing, is associated with MS.
15. Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.
15. 1. Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate.
2. The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response? 1. Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus. 2. There is no evidence suggesting there is any chromosomal involvement in developing MS. 3. Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS. 4. Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on.
2. 1. The exact cause of MS is not known, but there is a theory stating a slow virus is partially responsible. A failure of a part of the immune system may also be at fault. A genetic predisposition involving chromosomes 2, 3, 7, 11, 17, 19, and X may be involved.
5. The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test? 1. The client will have wires attached to the scalp and lights will flash off and on. 2. The machine will be loud and the client must not move the head during the test. 3. The client will drink a contrast medium 30 minutes to one (1) hour before the test. 4. The test will be repeated at intervals during a five (5)- to six (6)-hour period.
2. MRI scans require the client to lie still and not move the body; the client should be warned about the loud noise.
16. The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which preprocedure intervention has priority? 1. Keep the client NPO. 2. Instruct the client to void. 3. Place in the lithotomy position. 4. Assess the client's pedal pulse.
2. The client should void prior to this procedure to help prevent accidental puncture of the bladder during the procedure.
19. The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on. 2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.
2. The client will not be able to use the arms as a result of the paralysis but can blink the eyes as long as the nurse asks simple "yes-or-no" questions.
18. The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.
2. The client with Guillain-Barré syndrome will not be able to move the extremities; therefore, preventing muscle atrophy is an appropriate long-term goal.
25. 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. These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral blurred vision.
4. The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make? 1. "Why are you crying? The medication will help the disease." 2. "You seem upset. I will sit down and we can talk for awhile." 3. "Multiple sclerosis is a disease that has good times and bad times." 4. "I will have the chaplain come and stay with you for a while."
2. This is stating a fact and offering self. Both are therapeutic techniques for conversations.
14. Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."
2. This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits.
20. The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."
20. 1. Clients with this syndrome usually have a full recovery, but it may take up to one (1) year.
24. The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply. 1. Refer client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation.
24. 1. The physical therapist is an important part of the rehabilitation team who ad dresses the client's muscle deterioration resulting from the disease process and immobility. 3. The social worker could help with financial concerns, job issues, and issues concerning the long rehabilitation time for this syndrome. 4. Pain may or may not be an issue with this syndrome. Each client is different but a plan needs to be established to address pain if it occurs. 5. This is an excellent resource for the client and the family.
28. 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.
28. 1. 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.
7. The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance? 1. The client refuses to have a gastrostomy feeding. 2. The client wants to discuss if she should tell her fiancé. 3. The client tells the nurse life is not worth living anymore. 4. The client needs the flu and pneumonia vaccines.
3. A potential suicide statement is priority for the nurse when caring for the client with MS.
22. The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.40, PaO2 88, PaCO2 35, and HCO3 24.
3. A pulse oximeter reading of less than 93% warrants immediate intervention; a 90% peripheral oxygen saturation indicates a PaO 2 of about 60 (normal, 80 to 100). When the client is placed on the ventilator, this should cause the client's oxygen level to improve.
27. Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the signs/symptoms of the disease process? 1. There is no surgical option. 2. A transsphenoidal hypophysectomy. 3. A thymectomy. 4. An adrenalectomy.
3. 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.
10. The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented? 1. Discuss discontinuing the proton pump inhibitor with the HCP. 2. Hold the medication until after all cultures have been obtained. 3. Monitor the client's serum blood glucose levels frequently. 4. Provide supplemental dietary sodium with the client's meals.
3. Steroids interfere with glucose metabolism by blocking the action of insulin; therefore, the blood glucose levels should be monitored.
3. The 30-year-old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two (2) times in the month. Which question is most important for the nurse to ask the client? 1. "Have you experienced any difficulty with your menstrual cycle?" 2. "Have you noticed a rash across the bridge of your nose?" 3. "Do you get tired easily and sometimes have problems swallowing?" 4. "Are you taking birth control pills to prevent conception?"
3. These are clinical manifestation of MS and can go undiagnosed for years be cause of the remitting-relapsing nature of the disease. Fatigue and difficulty swallowing are other symptoms of MS.
30. 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.
30. 1. Hypovolemia is a complication of plasmapheresis, especially during the procedure, when up to 15% of the blood volume is in the cell separator.
31. 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."
31. 1. 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.
33. 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.
33. 1. Position changes promote lung expansion, and coughing helps clear secretions from the tracheobronchial tree. 2. This position expands the lungs and alleviates pressure from the diaphragm. 4. The medications should be administered 30 minutes before the meal to provide optimal muscle strength for swallowing and chewing.
35. 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.
35. 1. This medication promotes muscle contraction, which improves muscle strength, which, in turn, allows the client to perform ADLs without assistance.
36. 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.
36. 1. This medication will increase muscle strength to help enhance swallowing and chewing during meals.
13. Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.
4. Ascending paralysis is the classic symptom of Guillain-Barré syndrome.
26. 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. Clients with MG show a significant improvement of muscle strength lasting approximately five (5) minutes when Tensilon (edrophonium chloride) is injected.
34. 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. 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.
1. The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention? 1. The client has scanning speech and diplopia. 2. The client has dysarthria and scotomas. 3. The client has muscle weakness and spasticity. 4. The client has a congested cough and dysphagia.
4. Dysphagia is a common problem of clients diagnosed with multiple sclerosis, and this places the client at risk for aspiration pneumonia. Some clients diagnosed with multiple sclerosis eventually become immobile and are at risk for pneumonia.
17. Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.
4. Guillain-Barré syndrome has ascending paralysis causing respiratory failure. Therefore, breathing pattern is priority.
21. The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement post-procedure? 1. Monitor the client for hypotension. 2. Apply pressure to the puncture site. 3. Test the client's cerebrospinal fluid. 4. Increase the client's fluid intake.
4. Increased fluid intake will help prevent a post-procedure headache, which may occur after a lumbar puncture.
23. The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement? 1. Tell the wife she must stop crying. 2. Escort the wife out of the room. 3. Medicate the client immediately. 4. Acknowledge the wife's fears.
4. It is scary for a wife to see her loved one with a tube down his mouth and all the machines around them. The nurse should help the wife by acknowl edging her fears.
29. 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 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.
6. The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented? 1. Consult the physical therapist for assistive devices for mobility. 2. Determine if the client has a legal power of attorney. 3. Ask if the client would like to talk to the hospital chaplain. 4. Discuss the client's wishes regarding end-of-life care.
4. The client should make personal choices about end-of-life issues while it is possible to do so. This client is progressing toward immobility and all the complications related to it.
32. 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 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.
8. The nurse and a licensed practical nurse (LPN) are caring for a group of clients.Which nursing task should not be assigned to the LPN? 1. Administer a skeletal muscle relaxant to a client diagnosed with low back pain. 2. Discuss bowel regimen medications with the HCP for the client on strict bedrest. 3. Draw morning blood work on the client diagnosed with bacterial meningitis. 4. Teach self-catheterization to the client diagnosed with multiple sclerosis.
4. The nurse should not assign assessing, teaching, or evaluation to the LPN. Evaluating the client's ability to per form self-catheterization should not be assigned to the LPN.
9. The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse? 1. Encourage the therapy if it is not contraindicated by the medical regimen. 2. Tell the client only the health-care provider should discuss this with him. 3. Ask how his significant other feels about this deviation from the medical regimen. 4. Suggest the client research an investigational therapy instead.
9. 1. The nurse should listen without being judgmental about any alternative therapy the client is considering. Alternative therapies, such as massage and relaxation, are frequently beneficial and enhance the medical regimen.
