NUR 202 Module G Practice
What nursing intervention is anticipated for a client with Guillain-Barré syndrome?
Maintaining ventilator settings to support respiration (this is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected.)
The client arrives to the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease?
Myasthenia gravis (MG)
The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching?
"I can continue to take over-the-counter drugs."
The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the physician will request which medication to aid in the diagnosis of MG?
*Edrophonium chloride (Tensilon)* Edrophonium chloride (Tensilon) is used most often for testing for MG because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors
What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia?
Chew on the unaffected side.
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving immunoglobulin (IVIG). Which client finding warrants immediate evaluation?
Headache with stiff neck (This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy).
The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction?
I should call 911 if a sudden increase in weakness occurs (A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member should call 911 for emergency assistance).
What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS) share in common?
Increased risk for respiratory complications.
To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?
Ineffective Coughing.
The client has Parkinson disease (PD). Which nursing intervention best protects the client from injury?
Monitoring the client's sleep patterns (Clients with PD tend to not sleep well at night because of drug therapy and the disease itself. Some clients nap for short periods during the day and may not be aware that they have done so. This sleep misperception could put the client at risk for injury (e.g., falling asleep while driving).
Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit?
Nystagmus, Scanning Speech, and Intention Tremors. This group of signs is known as Charcot's triad.
A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority?
Potential for aspiration related to difficulty with swallowing
The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase inhibitor (ChE). The nurse plans to contact the physician if the client is taking which medication?
Procainamide (Pronestyl) . (Procainamide (Pronestyl) should be avoided because it may increase the client's weakness)
The client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention will the nurse perform first?
Raises the head of the bed to 45 degrees
A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?
Suction the client's oropharynx (A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway.)
A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority?
Take the medication according to a specific schedule (A priority of care for a client with myasthenia gravis is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing).
Optimal teaching for the client with multiple sclerosis (MS) who is experiencing urinary retention includes:
Using Crede's maneuver, and Monitoring for and reporting signs of urinary tract infection.
The client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse?
"Narcotics will be needed for pain relief." ( Mild analgesics, not narcotics, are used for pain associated with Bell's palsy).
A nurse is caring for two clients. One has Parkinson disease and the other has myasthenia gravis. For what common complication associated with both disorders should the nurse assess these clients?
Difficulty Swallowing.
The nurse is teaching the client newly diagnosed with migraine about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan?
"I must not miss a meal!" (Missing meals is a trigger for many people suffering from migraines. The client should not skip any meals until the triggers are identified).
A client with migraine headaches is admitted for encephalogram (EEG). The nurse knows teaching is effective when the client makes the following statement?
"I will need to avoid caffeine."
Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching?
"I will take a hot bath to help relax my muscles." (Hot baths tend to increase symptoms and may result in burns because of decreased sensation.)
The nursing instructor asks the nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct?
"Choking, coughing, or eructation may occur in both disorders." (Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects swallowing, chewing, and biting).
The client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response?
"Contact the Guillain-Barré Foundation International for resources."
The client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring?
A classic migraine
A client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply?
A decreased number of functioning acetylcholine receptor (AChR) sites. (One of the pathologic changes is electron microscopic evidence of fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites).
The client is being evaluated for signs associated with myasthenia crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis?
Abdominal cramps, blurred vision, facial muscle twitching (Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs.).
The client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse?
Administer medications promptly on schedule to maintain therapeutic drug levels & Small frequent meals
The client is admitted with trigeminal neuralgia for a percutaneous sterotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next?
Administers pain medication as requested
A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?
Aspiration. (Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life.).
When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?
Avoid leaning forward. (The client with Parkinson disease often has a stooped posture because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.)
The nurse encourages the ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique?
Blinking for yes or no.
A client is diagnosed with trigeminal neuralgia. Which medications should the nurse anticipate will be prescribed for this client?
Carbamazepine (Tegretol) and Baclofen (Lioresal). (Carbamazepine is an anticonvulsant, antineuraligic drug used to control pain in trigeminal neuralgia and to prevent future attacks. Baclofen is an antispasmodic that may be used alone or in conjunction with Tegretol.)
A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?
Chest tightness (Triptan drugs are contraindicated in clients with coronary artery disease because they can cause arterial narrowing; the nurse should instruct the client to not take the medication until the nurse can talk with the prescribing health care provider).
The client has Guillain-Barré syndrome. Which interdisciplinary health care team members will the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in the client with Guillain-Barré syndrome?
Family, dietician, and Occupational therapist (OT).
The client with advanced Guillain-Barré syndrome (GBS) is no longer able to perform ADLs independently. Which priority problem best identifies measures to prevent pressure ulcers?
Impaired Physical Mobility related to weakness, paralysis, and ataxia
During the neurological assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, the nurse expects that the client will manifest:
Increased muscular weakness (Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated).
The client with Parkinson disease is being discharged home with his wife. To ensure compliance with the management plan, which discharge action is most effective?
Involving the client and his wife in developing a plan of care
Which information should be included in the teaching plan for the client who is prescribed sumatriptan (Imitrex) for migraine headache?
Is contraindicated in people with coronary artery disease (In addition to promoting therapeutic cerebral vasoconstriction, sumatriptan promotes undesirable coronary artery vasoconstriction. Coronary vasoconstriction may cause harm to the client with coronary artery disease. For maximum effectiveness, sumatriptan should be administered at the onset of migraine headache. Sumatriptan may be given orally, subcutaneously, or as a nasal spray. The maximum adult dose of sumatriptan is two 6 mg doses in a 24 hour period for a total of 12 milligrams. The two doses must be separated by at least an hour. The second dose should not be administered unless some response was observed with the first dose).
Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis?
Monitoring respiratory status.
A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?
Raise the head of the bed. (Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration).
A client with myasthenia gravis continues to become weaker despite treatment with neostigmine (Prostigmin). What reason should the nurse identify for the health care provider's prescription for edrophonium (Enlon)?
Rule out cholinergic crisis (Edrophonium improves muscle strength in myasthenic crisis; weakness persists if symptoms are caused by cholinergic crisis, which can result from toxic levels of neostigmine).
A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?
Space activities throughout the day. (Spacing activities will encourage maximum functioning within the limits of strength and fatigue.)
A client with the diagnosis of Parkinson disease asks the nurse, "Why do I drool so much?" Which is the nurse's best response?
"You have a loss of involuntary movements." (The client with this disease cannot execute automatic involuntary movements and has difficulty swallowing saliva. It is known that bradykinesia and muscular weakness cause difficulty in swallowing saliva).
The client with amyotrophic lateral sclerosis (ALS) is degenerating rapidly and will soon need respiratory support. What will the nurse plan to review with this client?
Advance Directives (Mechanical ventilation enables the client to breathe and prolongs survival, but it will not alter progression of the disease. For this reason, many clients elect not to be placed on a mechanical ventilator, according to their wishes or advance directives).
The client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What will the nurse do next?
Allow the client to remain undisturbed
A client, residing in an assisted living facility, is diagnosed with Parkinson disease and the health care provider prescribes selegiline (Eldepryl). What precaution should the nurse teach the client?
Change positions slowly (A common side effect of selegiline is dizziness. Safety precautions are necessary to prevent falls caused by orthostatic hypotension).
An ambulatory female client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a (Avonex). What adverse effects should the nurse explain may occur when taking this medication?
Depression, Flulike symptoms, constipation and Increased heart rate (Central nervous system effects include depression that may lead to suicide attempts. Gastrointestinal side effects include constipation, diarrhea, vomiting, and abdominal pain. Interferon immune modifier causes flulike symptoms, such as fever, muscle aches, and lethargy. Drugs for increased heart rate include side effects such as tachycardia, palpitations, and hypertension. An integumentary response to this drug is sweating, not lack of perspiration (anhidrosis)).
A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?
Swimming. (Swimming helps keep the muscles supple, without requiring fine motor activity.)
The female client with newly diagnosed migraine is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions?
"I must report any chest pain right away." (Chest pain must be reported immediately with the use of sumatriptan).
Which nursing action is specific to the plan of care for a client with trigeminal neuralgia?
Be alert to prevent dehydration or starvation (Pain may prevent the client from ingesting anything by mouth. Facial exercises may precipitate an attack. Hot or cold foods or compresses should be avoided because they may trigger a painful attack. Brushing the teeth may initiate an acute attack of trigeminal neuralgia; often clients must limit oral hygiene to rinsing the mouth.).
Which statement by the nursing student illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)?
The client's respiratory status and muscle function are affected by both diseases.
The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis (ALS) who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions?
"I will need frequent checks of my liver enzymes." (May cause liver toxicity. This must also be taken on an empty stomach, twice a day, and may cause tachycardia).
The nurse is teaching the client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates correct understanding of the pathophysiology of the disease?
"Parts of my nervous system have plaques." (MS is characterized by an inflammatory response that results in diffuse random or patchy areas of plaque in the white matter of the central nervous system).