Nanny U3

The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome. An important question to ask related to the diagnosis is which of the following?- a "Have you experienced any viral infections in the last month?" b "Have you experienced any ptosis in the last few weeks?" c "Have you had difficulty with urination in the last 6 weeks?" d "Have you experienced any viral infections in the last month?"

answer: a/d (they'e the same doh!) An antecedent event (most often a viral infection) precipitates clinical presentation. The antecedent event usually occurs about 2 weeks before the symptoms begin. Ptosis is a common symptom associated with myasthenia gravis. Urination and development of allergies are not associated with Guillain-Barre.

The nurse is caring for a patient who is hospitalized with an exacerbation of MS. To ensure the patient's safety, what nursing action should be performed? A) Ensure that suction apparatus is set up at the bedside. B) Pad the patient's bed rails. C) Maintain bed rest whenever possible. D) Provide several small meals each day.

Ans: A Feedback: Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand. Bed rest should be generally be minimized, not maximized, and there is no need to pad the patient's bed rails or to provide multiple small meals.

A nurse is teaching a client who was recently diagnosed with myasthenia gravis. Which statement should the nurse include in her teaching? a. "You'll continue to experience progressive muscle weakness and sensory deficits." b. "You'll need to take edrophonium (Tensilon) to treat the disease." c. "The disease is a disorder of motor and sensory dysfunction." d. "This disease doesn't cause sensory impairment."

Answer: D Rationale: Myasthenia gravis affects motor function; therefore, the nurse should inform the client that sensory impairments won't occur. This disease is chronic; there's no cure. It can be managed with edrophonium in the diagnostic phase; however, this drug isn't used to treat the condition.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurologic symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period? (couldn't find options)

Answer: Logroll the client from side to side. Explanation: Logrolling the client maintains alignment of his hips and shoulders and eliminates twisting in his operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

The nurse practitioner prescribes the medication of choice for an MS patient who is experiencing disabling episodes of muscle spasms, especially at night. Which of the following is the drug most likely prescribed in this scenario? a Dantrium b Lioresal c Zanaflex dValium

Correct response: b. Lioresal Explanation: Baclofen (Lioresal), a gamma-aminobutyric acid (GABA) agonist, is the medication of choice for treating spasticity. It can be administered orally or by intrathecal injection.

A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS? A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes B) Flexor spasm, clonus, and negative Babinskis reflex C) Blurred vision, intention tremor, and urinary hesitancy D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

Answer C 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 Babinskis reflex is found in MS. Abdominal reflexes are absent with MS.

A patient has been admitted to the neurologic ICU with a diagnosis of a brain tumor. The patient is scheduled to have a tumor resection/removal in the morning. Which of the following assessment parameters should the nurse include in the initial assessment? A) Gag reflex B) Deep tendon reflexes C) Abdominal girth D) Hearing acuity

Answer: A Feedback: Preoperatively, the gag reflex and ability to swallow are evaluated. In patients with diminished gag response, care includes teaching the patient to direct food and fluids toward the unaffected side, having the patient sit upright to eat, offering a semisoft diet, and having suction readily available. Deep tendon reflexes, abdominal girth, and hearing acuity are less commonly affected by brain tumors.)

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assess in this patient? A. Pruritus B. Dyskinesia C. Lactose intolerance D. Diarrhea

Answer: B Feedback: Within 5 to 10 years of taking levodopa, most patients develop a response to the medication characterized by dyskinesia (abnormal involuntary movements). Another potential complication of long-term dopaminergic medication use is neuroleptic malignant syndrome characterized by severe rigidity, stupor, and hyperthermia. Side effects of long-term Sinemet therapy are not pruritus, lactose intolerance, or diarrhea.)

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? a. Ask if the client has had a bowel movement. b. Ask the client if there is pain on ambulation c. Have the client lie on the back and lift the leg, keeping it straight. d. Ask if the client can walk.

Answer: C Rationale: A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.

A client is diagnosed with amyotrophic lateral sclerosis (ALS) in the early stages. Which medication would the nurse most likely expect to be prescribed as treatment? a. Riluzole b Benztropine mesylate c. Amantadine d. Bromocriptine

Answer: a Explanation:Riluzole is the only medication that is approved for use in treating ALS. It is used for its neuroprotective effect in the early stages of the disease. Benztropine amantadine and bromocriptine are used to treat Parkinson's disease.

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients? a. Gag reflex and bowel sounds b. Respiratory status c. Condition of skin d. Urinary output and capillary refill

Answer: a Gag reflex and bowel sounds Explanation:Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nutrition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? a Respiratory b GI c Urinary d Skin

Answer: a Respiratory Explanation:Because of its possible rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency. After baseline values are identified, assessment of changes in muscle strength and respiratory function alert the team to the physical and respiratory needs of the client. The other three choices may become problem areas later, but respiratory issues are always a priority.

A patient is diagnosed with amyotrophic lateral sclerosis, also known as ALS or Lou Gehrig's disease. The nurse understands that the symptoms of the disease will begin in what way? a. Ascending paralysis b Numbness and tingling in the lower extremities c. Weakness starting in the muscles supplied by the cranial nerves d. Jerky, uncontrolled movements in the extremities

Answer: c Explanation: The chief symptoms are fatigue, progressive muscle weakness, cramps, fasciculations (twitching), and incoordination. In about 25% of patients, weakness starts in the muscles supplied by the cranial nerves, and difficulty in talking, swallowing, and ultimately breathing occurs.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? a Patchy blindness b Loss of proprioception c Diplopia and ptosis d Numbness

C Diplopia and ptosis Explanation: The initial manifestation of myasthenia gravis in two-thirds of clients involves the ocular muscles; diplopia and ptosis are common. Muscle weakness and hyporeflexia of the lower extremities are associated with Guillain-Barre syndrome. Facial distortion and pain are associated with Bell's palsy and tic douloureux.