NUR 414 Final Exam

A pt with GBS has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? A. Ascending weakness B. Skin desquamation C. Localized seizures D. Hyperactive reflexes

A. Ascending weakness

The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? A. "I will avoid alcohol." B. "I will take acetaminophen for pain" C. "I will be sure to take naps throughout the day." D. "I will eat small frequent meals."

B. "I will take acetaminophen for pain." Acetaminophen is damaging to the liver and is contraindicated in clients with hepatitis. Clients should avoid alcohol, eat small frequent meals, and be sure to get plenty of rest.

A client diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the healthcare provider include in this client's plan of care? A. Provide high-protein feedings B. Monitor the blood glucose C. Institute droplet precautions D. Weigh once a week

B. Monitor the blood glucose Interventions for this patient include blood glucose monitoring (because of decreased glycogen synthesis and storage), monitoring PT and INR (because of decreased clotting factors), checking reflexes (because of the neurological effects of increased ammonia), providing diet/feedings that are low in protein (to decrease ammonia levels), and following standard precautions. The client should be weighed every day.

What does the RN understand that clients with myasthenia gravis, GBS, and amyotrophic lateral sclerosis (ALS) share in common? A. Involuntary twitching of small muscle groups B. Progressive deterioration until death C. Increased risk for respiratory complications D. Deficiencies of essential neurotransmitters

C. Increased risk for respiratory complications

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure? A. Keeping pt in trendelenburg position for at least 2 hr. B. Placing the client in high fowlers immediately after the procedure C. Maintaining the client in supine position for several hours. D. Encouraging the client to ambulate every hr for at least 6 hours

C. Maintaining the client in the supine position for several hours

An RN enters the room of a pt with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? A. Call HCP B. Perform tracheal suctioning C. Raise HOB D. Administer O2

C. Raise the HOB

The family member of a pt with newly diagnosed GBS comes out to the nurse's station and informs that nurse that the client states he is having difficulty breathing. What is the first action the nurse should do? A. Notify HCP B. Assure the family member that this is a normal response C. Call a code, as this client with need endotracheal intubation D. Inform the family member the RN will be in to assess the client

D. Inform the family member the RN will be in to assess the client

A pt with a 5 yr hx of myasthenia gravis is admitted to the hospital because of exacerbation. When assessing the pt, the RN identifies ptosis, dysarthria, dysphagia, and muscle weakness, The nurse expects what client response? A. Strength improves immediately after meals B. Weakness improves with muscle use C. Weakness decreases after hot baths D. Strength decreases with repeated muscle use

D. Strength decreases with repeated muscle use Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement.

The RN is caring for a pt with myasthenia gravis. The RN expects which test to be ordered to differentiate between a myasthenic crisis from a cholinergic crisis? A. Lumbar puncture B. Edrophonium cholride C. MRI D. CBC

B. Edrophonium chloride (IV) The Tensilon test is used in the pt with myasthenia gravis to distinguish between myasthenic crisis and cholinergic crisis. Symptoms of flaccid paralysis improve if the cause is myasthenic crisis and worsen if it's cholinergic crisis. In the event the symptoms are the result of a cholinergic crisis, atropine must be readily available at the bedside

The respiratory status of a client with GBS progressively deteriorates and a tracheostomy is performed. NG tube feedings are prescribed. The RN should manage the trach cuff by: A. Deflating the cuff after the tube feeding B. Inflating the cuff before the feeding and 30 min after each feeding C. Deflating the cuff before starting each feeding D. Inflating the cuff for one hour before and after each feeding

B. Inflating the cuff before the feeding and for 30 min after each feeding

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is: A. "All family members, including your child, need to wash their hands after using the bathroom." B. "I suggest that you buy a commode exclusively for your child's use." C. "You will need to clean the bathroom from top to bottom every time a family member uses it." D. "Your child may use the bathroom, but you need to use disposable toilet covers."

A. "All family members, including your child, need to wash their hands after using the bathroom." Hepatitis A is spread via the fecal-oral route; transmission is prevented by proper handwashing. Buying a commode exclusively for the child's use is unnecessary; cleansing the toilet and washing the hands should control the transmission of microorganisms. It is not feasible to clean "from top to bottom" each time the bathroom is used. The use of disposable toilet covers is inadequate to prevent the spread of microorganisms if the bathroom used by the child also is used by others. Handwashing by all family members must be part of the plan to prevent the spread of hepatitis to other family members.

A client is admitted to the hospital with ascites. The client reports drinking a quart of vodka mixed in orange juice every day for the past three months. To assess the potential for withdrawal symptoms, which question would be appropriate for the nurse to ask the client? A. "When was your last drink of vodka?" B. "Why do you mix the vodka with orange juice?" C. "What prompts your drinking episodes?" D. "Do you also eat when you drink?"

A. "When was your last drink of vodka?" The nurse must determine when the client had the last drink to gauge when the body may react to lack of alcohol (withdrawal). Factors that prompt drinking are important, but do not affect the body's response to withdrawal from the substance. Whether the client also eats when the client drinks will not influence the body's response to withdrawal from the alcohol. Whether the client mixes vodka with orange juice will not influence the body's withdrawal from the alcohol.

A school health nurse is teaching a health class to 12-year-olds about hepatitis C. Which statement by a student indicates an understanding of the origin of the disease? A. "You can catch it while you're getting a tattoo." B. "The disease is passed from person to person by casual contact." C. "People working at restaurants can give it to you if they don't wash their hands." D. "You're more likely to get it in crowded living conditions.

A. "You can catch it while you're getting a tattoo." The hepatitis C virus (HCV) is a bloodborne pathogen; it can be acquired during the application of a tattoo with equipment that is contaminated with the hepatitis C virus. Hepatitis C is not transmitted by close contact in crowded spaces; HCV is a bloodborne pathogen. HCV is not transmitted by casual contact; it is a bloodborne pathogen. The fecal-oral route of transmission is associated with hepatitis A, not hepatitis C.

During the morning assessment of a client with cirrhosis, you note the client is disoriented to person and place. In addition, while assessing the upper extremities, the client's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Ammonia level of 68 µ/dL B. Creatinine level of 2.9 mg/dL C. Potassium level of 3.7 mmol/L D. Calcium level of 10.9 mg/dL

A. Ammonia level of 68 µ/dL Based on the assessment findings and the fact the client has cirrhosis, the client is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings (Normal ammonia: 10-80)

Which factors are associated with developing guillain-barre syndrome? Select all that apply. A. Epstein-barr infection B. Recent upper respiratory infection C. Client is 4 y.o D. Recent flu vaccination E. diabetes

A. Epstein-barr infection B. Recent upper respiratory infection D. Recent flu vaccination Risk factors for developing GBS include: experiencing upper respiratory infection, GI infection, Epstein-Barr infection, HIV/AIDS, vaccination (flu/swine flu).

The nurse is caring for a client who is scheduled to have a percutaneous liver biopsy. Which findings warrant the postponement of the procedure? Select all that apply. A. Hemoglobin less than 9 g/dL B. Platelet count of 160,000/mm3 C. Marked ascites D. Ecchymosis and purpura E. Hepatic cirrhosis

A. Hemoglobin less than 9 g/dL C. Marked ascites D. Ecchymosis and purpura To do a liver biopsy when a client has marked ascites increases the risk of leakage of ascitic fluid. The liver biopsy should be postponed. A client with a hemoglobin of less than 9 g/dL should not have a liver biopsy because the client cannot take the risk of the puncture of a hepatic blood vessel. A diagnosis of hepatic cirrhosis is not a reason to postpone a liver biopsy, because it is done to detect the presence of hepatic cirrhosis. Although a platelet count of 160,000/mm3 is within the low range of the expected platelet count for an adult, a liver biopsy is not contraindicated. A count of less than 50,000/mm3 is critical and requires postponement of the test. Ecchymosis and purpura are signs of bruising and If the client has numerous bruises it may indicate deficient thrombocytes or prolonged clotting; both are contraindications for a percutaneous liver biopsy.

A client with cirrhosis of the liver develops ascites, and the health care provider prescribes spironolactone. What should the nurse monitor the client for? A. Hyperkalemia B. Tachycardia C. Hypoglycemia D. Ecchymosis

A. Hyperkalemia Spironolactone (Aldactone) is a potassium-sparing diuretic that is used to treat clients with ascites; therefore, the nurse should monitor the client for signs and symptoms of hyperkalemia. Bruising and purpura are associated with cirrhosis, not with the administration of spironolactone. Spironolactone does not cause tachycardia. Spironolactone does not cause hypoglycemia.

The physician orders Lactulose 30 mL by mouth per day for a client with cirrhosis. What finding below demonstrates the medication is working effectively? A. Improvement in level of consciousness B. Presence of asterixis C. Decreased albumin levels D. Absence of fruity breath

A. Improvement in level of consciousness A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands). This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status, decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level. Fruity breath is associated with DKA not hepatic encephalopathy.

An RN is caring for a client newly diagnosed with GBS. The RN expects that which procedure will be considered as a treatment option? A. Plasmapheresis B. Hemodialysis C. Immunosuppression therapy D. Thrombolytic therapy

A. Plasmapheresis Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of the solution. A pt with GBS, in the absence of kidney disease, does not need dialysis. GBS is not a hematological disorder; thrombolytic therapy isn't required. GBS is not an autoimmune disorder; immunosuppression therapy isn't required.

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to: A. Stop the transfusion B. Monitor the hourly urinary output C. Obtain the vital signs D. Assess the pain further

A. Stop the transfusion Flank pain is an adaptation associated with a hemolytic transfusion reaction; it is caused by agglutination of red cells in the kidneys and renal vasoconstriction. The infusion must be stopped to prevent further instillation of blood, which is being viewed as foreign by the body. Although obtaining the vital signs, assessing the pain further, and monitoring the hourly urinary output will be done eventually, they are not the priority actions.

A client with ascites has a paracentesis, and 1500 mL of fluid is removed. The nurse recognizes that it is important to monitor the client for what signs of complications that may occur immediately after the procedure? Select all that apply. A. Temperature of 100.1 B. Blood pressure of 90/40 C. Heart rate of 110 D. Pulmonary congestion E. Hypoactive bowel sounds

B. Blood pressure of 90/40 C. Heart rate of 110 Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; a rapid, thready pulse compensates for this shift. Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia; the decrease in blood pressure is evidence of hypovolemia. Decreased peristalsis is not the priority. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not the lungs. Fever is not a concern at this time. If the client were to develop an infection as a result of the procedure, a fever will occur several days after the procedure.

A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. A priority nursing action during the first 48 hours after the client's admission is to: A. Determine the client's reasons for drinking. B. Monitor the client's vital signs C. Improve the client's nutritional status. D. Increase the client's fluid intake.

B. Monitor the client's vital signs A client's vital signs, especially the pulse and temperature, will increase before the client demonstrates any of the more severe symptoms of withdrawal from alcohol. Increasing intake is contraindicated initially because it may cause cerebral edema. Improving nutritional status becomes a priority after the problems of the withdrawal period have subsided. Determining the client's reasons for drinking is not a priority until after the detoxification process.

A client with guillain-barre syndrome has a feeding tube for nutrition. What priority actions should the nurse perform prior to starting the tube feeding? Select all that apply. A. Don sterile gloves B. Raise HOB to 30 degrees C. Assess the client's bowel sounds D. Check tube placement E. Check the client's gastric residual

B. Raise HOB to 30 degrees C. Assess bowel sounds D. Check tube placement E. Check gastric residual Some pts who experience GBS will need a feeding tube because they're no longer able to swallow safely d/t paralysis of the cranial nerves that help with swallowing. GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeing the nurse should always assess for bowel sounds, check gastric residual, placement of the tube. Elevation of the HOB helps to decrease risk of aspiration.

During report you learn that the pt you will be caring for has GBS. As the RN you know this disease tends to present with: A. S/S that are symmetrical and ascending that star in the upper extremities B. S/S that are symmetrical and ascending that start in the lower extremities C. S/S that are asymmetrical and ascending that start in the upper extremities D. S/S that are unilateral and descending that start in the lower extremeties

B. S/S that are symmetrical and ascending that start in the lower extremities

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? A. Portal hypotension B. Kidney malfunction C. Diminished plasma protein level D. Decreased production of potassium

C. Diminished plasma protein level The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the liver's ability to man

A HCP determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Intention tremors of the hands B. Nonintention tremors of the extremities C. Drooping of the upper eyelids D. Double vision E. Problems with cognition F. Difficulty swallowing saliva

C. Drooping of the upper eyelids D. Double vision F. Difficulty swallowing saliva Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves are often affected; difficulty with swallowing is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial III (oculomotor) dysfunction. Myasthenia gravis is a neruomuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention gtremors of the extremities are associated with Parkinson disease.

A health care provider schedules a paracentesis for a client with ascites. What should the nurse include in the client's teaching plan? A. Consume a diet low in fat for three days before the procedure. B. Stay on a liquid diet for 24 hours after the procedure. C. Empty the bladder immediately before the procedure. D. Maintain a supine position during the procedure.

C. Empty the bladder immediately before the procedure. The bladder must be emptied immediately before the procedure to decrease the chance of puncture with the trocar used in a paracentesis. A paracentesis usually is performed with the client in the Fowler position to assist the flow of fluid by gravity. Eating a diet low in fat for three days before the procedure is not necessary for a paracentesis. Staying on a liquid diet is not necessary for a paracentesis.

A nurse is caring for a client with ascites who is to receive intravenous (IV) albumin. The nurse expects that the albumin replacement will decrease the: A. Capillary perfusion and blood pressure B. Ascites and blood ammonia levels C. Peripheral edema and hematocrit level D. Venous stasis and blood urea nitrogen level

C. Peripheral edema and hematocrit level Serum albumin is administered to maintain serum levels and normal oncotic (osmotic) pressure; it does this by pulling fluid from the interstitial spaces into the intravascular compartment. Serum albumin does affect blood ammonia levels; fluid accumulated in the abdominal cavity is removed via a paracentesis. The administration of albumin results in a shift of fluid from the interstitial to the intravascular compartment, which probably will increase the blood pressure. Albumin administration does not affect venous stasis or the blood urea nitrogen

A pt. with myasthenia gravis improves and is discharged. Discharge meds include pyridostigmine 10 mg orally every 6 hr. The RN evaluates that the drug regimen is understood when the client says, "I should: A. Count my pulse before taking the drug B. Drink milk with each dose C. Set my alarm clock to take my medication D. Take this med on an empty stomach

C. Set my alarm clock to take my medication

An RN is caring for a pt with GBS. The RN identifies that the pt is having difficulty expectorating respiratory secretions. What should be the RN's first intervention? A. Auscultate for breath sounds B. Administer O2 via NC C. Suction the pt's oropharynx D. Place the client in orthopneic postiion

C. Suction the pt's oropharynx

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed an an anticholinergic medication is prescribed. The RN is planning care with the client and spouse. Which instruction is the priority? A. Take a stool softener daily B. Eat foods that are pureed C. Take the medication according to a specific schedule D. perform range of motion exercises

C. Take the med according to a specific schedule Anticholinergic medications should be taken before meals because it enhances chewing and swallowing. Dysphagia usually isn't an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dysphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, ROM exercises prevent joint contractures rather that promote muscle strength. Anticholinergic meds taken for myasthenia gravis cause a relaxation of smooth muscle, resulting in diarrhea rather than consitpation.

A patient diagnosed with hepatitis develops splenomegaly. When reviewing the laboratory report, which of the following results will the healthcare provider anticipate? A. Polycythemia B. Leukocytosis C. Thrombocytopenia D. Neutrophilia

C. Thrombocytopenia The spleen acts as a reservoir for platelets. When the spleen is enlarged, as with splenomegaly, up to 90 percent of a person's thrombocytes can be sequestered within the enlarged spleen.