AH2 Chapter 44
The nurse is teaching a client about the risk factors of restless legs syndrome. Which statement by the client indicates a correct understanding of the nurse's instruction? A) "Cigarettes and alcohol must be avoided." B) "I need to exercise my legs before bedtime." C) "It is important to stay off my feet." D) "Over-the-counter drugs must not be taken."
ANS A "Cigarettes and alcohol must be avoided." The correct statement about the risks of restless legs syndrome is cigarettes and alcohol must be avoided. Clients with restless legs syndrome need to avoid as many risk factors as possible or make lifestyle modifications. Examples include avoiding caffeine and alcohol, quitting smoking, and losing weight.Clients with RLS need to be encouraged to exercise but not engage in strenuous activity within 2-3 hours before bedtime. Use of over-the-counter drugs is not contraindicated for clients with restless legs syndrome.
A client's spouse expresses concern that the client, who has Guillain-Barré syndrome (GBS), is becoming very depressed and will not leave the house. What is the nurse's best response? A) "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." B) "Try inviting several people over so the client won't have to go out." C) "Let your spouse stay alone. Your spouse will get used to it." D) "This behavior is normal."
ANS A "Contact the Guillain-Barré Syndrome Foundation International for resources. Here is their contact information." The nurse's best response to a client's spouse about the client with GBS being depressed is referring the client to the GBS Foundation for resources. The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for clients and their families. The Foundation may be able to help the spouse and family find local support groups to assist the family with the transition.Inviting one close friend over is appropriate, but more than one might overwhelm the client. Telling the spouse to let the client say alone and that the behavior is normal is not helpful and inappropriate. Although depression is expected initially, some action does need to be taken to prevent further deterioration.
The nursing instructor asks a nursing student to compare Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A) "Difficulty chewing may occur in both disorders." B) "Both are disorders of the autonomic nervous system." C) "Facial twitching occurs in both disorders." D) "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."
ANS A "Difficulty chewing may occur in both disorders." The correct statement about Bell's palsy and trigeminal neuralgia is that problems with chewing can happen in both disorders. Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects facial expressions and chewing.Both Bell's Palsy and trigeminal neuralgia are disorders of the cranial nerves. Facial twitching can be a sign of trigeminal neuralgia, whereas Bell's palsy causes a unilateral facial paralysis. Bell's palsy is caused by the herpes simplex virus, unlike trigeminal neuralgia, which is thought to be caused by excessive firing of irritated nerve fibers in the trigeminal nerve.
A 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 a correct understanding of the nurse's instruction? A) "I will call 911 if a sudden increase in weakness occurs." B) "I will increase the dose if a sudden increase in weakness occurs." C) "The medication must be taken with a large meal." D) "The medication must be taken on an empty stomach."
ANS A "I will call 911 if a sudden increase in weakness occurs." The statement about cholinesterase inhibitors that shows a correct understanding of the nurse's instructions is that the family member will call 911 if there is a sudden increase in weakness. 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 must call 911 for emergency assistance.The dose of cholinesterase inhibitors would never be increased without provider supervision. The client needs to eat meals 45-60 minutes after taking cholinesterase inhibitors to avoid aspiration. Cholinesterase inhibitors must be taken with a small amount of food to help alleviate GI side effects.
A client is being evaluated for signs associated with myasthenic crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A) Abdominal cramps, blurred vision, facial muscle twitching B) Bowel and bladder incontinence, pallor, cyanosis C) Increased pulse, anoxia, decreased urine output D) Restlessness, increased salivation and tearing, dyspnea
ANS A Abdominal cramps, blurred vision, facial muscle twitching The nurse suspects a cholinergic crisis when the client experiences abdominal cramps, blurred vision, and facial muscle twitching. These are signs of an acute exacerbation of muscle weakness symptoms of cholinergic crisis caused by overmedication with cholinergic (anticholinesterase) drugs.Bowel and bladder incontinence, pallor, cyanosis, increased pulse, anoxia, and decreased urine output are symptoms indicating a myasthenic crisis. Restlessness, increased salivation and tearing, and dyspnea are symptoms indicating a mixed myasthenic-cholinergic crisis.
A client with trigeminal neuralgia is admitted for a percutaneous stereotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A) Administers pain medication as requested B) Ensures that the client has nothing by mouth (NPO) C) Ensures that the preoperative laboratory work is complete D) Performs a preoperative assessment
ANS A Administers pain medication as requested The next action the nurse needs to do is to give pain medication to the preoperative client with trigeminal neuralgia who is complaining of pain. Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia.After the client's pain has been addressed, the preoperative assessment can be completed, questions and concerns can be addressed, and any further testing can be completed. This client is not required to be NPO until after midnight.
The nurse encourages a ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A) Blinking for "yes" or "no" B) Moving lips to speak C) Using sign language D) Using a laptop to write
ANS A Blinking for "yes" or "no" To communicate, a ventilated client with advanced GBS needs to blink for "yes" or "no." A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate.Moving the lips is difficult to do around an endotracheal tube and is exhausting for the client. Sign language is very time-consuming to learn, unless the client and family already know it. Use of a laptop may prove too challenging for the client in advanced stages of GBS.
A client will be receiving plasmapheresis for treatment of Guillain-Barre'syndrome (GBS). Which posttreatment test will the nurse anticipate to be ordered? A) Electrolyte panel B) Electroencephalogram (EEG) C) Lumbar puncture D) Urinalysis
ANS A Electrolyte panel For the client receiving plasmapheresis for treatment of GBS, the nurse expects that an electrolyte panel will be ordered. Electrolytes will be checked since citrate-induced hypocalcemia is a complication of plasmapheresis.An electroencephalogram evaluates brain waves and is useful in detecting seizure activity. It would not be beneficial in this situation. A lumbar puncture might have been performed as part of the diagnostic process initially but not as part of posttreatment. There is no role for a urinalysis after plasmapheresis.
Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A) The client's respiratory status and muscle function are affected by both diseases. B) Both diseases are autoimmune diseases with ocular symptoms. C) Both diseases exhibit exacerbations and remissions of their signs and symptoms. D) Demyelination of neurons is a cause of both diseases.
ANS A The client's respiratory status and muscle function are affected by both diseases. The correct statement about the commonality between GBS and MG is that both diseases affect the respiratory and muscular system. Both GBS and MG affect clients' respiratory status and muscle function.Only MG is an autoimmune disease with ocular symptoms and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.
A 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? A) "It is important to post my medicine schedule at home, so my family knows my schedule." B) "I can continue to take over-the-counter drugs like before." C) "An extra supply of medicine must be kept in my car." D) "Wearing a watch with an alarm will remind me to take my medicine."
ANS B "I can continue to take over-the-counter drugs like before." Further teaching about medication administration is indicated when the client with MG says that he/she can still take over-the-counter drugs. Clients with MG must not take any over-the-counter medications without checking with their primary health care provider first.The client's medication schedule may be posted in the home for the benefit of family members. An extra supply of medication should be kept in the client's car or workplace to maintain therapeutic levels in case a dose was missed. The client may wear a watch with an alarm as a medication reminder to maintain therapeutic levels.
The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase (ChE) inhibitor. The nurse contacts the primary health care provider (PHCP) if the client is taking which medication? A) Acetaminophen (Tylenol) B) Diazepam (Valium) C) Furosemide (Lasix) D) Ibuprofen (Motrin)
ANS B Diazepam (Valium) The nurse contacts the PHCP if the client with MG who has been prescribed a ChE is also taking diazepam. Diazepam (Valium) would be avoided because it may increase the client's weakness.Acetaminophen (Tylenol) is an analgesic and antipyretic. It does not interact with ChE inhibitors. Furosemide (Lasix) is a diuretic and does not interact with ChE inhibitors. Ibuprofen (Motrin) is a nonsteroidal analgesic and does not interact with ChE inhibitors.
The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the primary health care provider (PHCP) will request which medication to aid in the diagnosis of MG? A) Atropine B) Edrophonium chloride (Tensilon) C) Methylprednisolone (Solu-Medrol) D) Ropinirole (Requip)
ANS B Edrophonium chloride (Tensilon) The nurse expects the PHCP to request edrophonium chloride for a newly admitted client suspected of having MG. Edrophonium chloride (Tensilon) and neostigmine bromide (Prostigmin) may be used for testing for MG. Tensilon is used most often 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.Atropine has parasympatholytic effects and is the antidote for edrophonium chloride. Methylprednisolone (Solu-Medrol) is a glucocorticoid that is used to treat inflammatory disorders. Ropinirole (Requip) is a dopamine agonist used in the treatment of restless leg syndrome (RLS).
The nurse admits a client with suspected Eaton-Lambert syndrome. The nurse anticipates that the primary health care provider (PHCP) will request which test to confirm the diagnosis? A) Doppler study B) Electromyography (EMG) C) Magnetic resonance imaging (MRI) D) Tensilon test
ANS B Electromyography (EMG) The nurse expects the PHCP to request an electromyography for the client suspected of having Eaton-Lambert syndrome. EMG is used to confirm the diagnosis of Eaton-Lambert syndrome, which is a form of myasthenia gravis (MG) that is often seen with small cell carcinoma of the lung.Doppler study is used frequently in the diagnosis of vascular disorders. MRI is not used to confirm the diagnosis of Eaton-Lambert syndrome. The Tensilon test is used as a diagnostic test in MG, but it is not used to confirm the diagnosis of Eaton-Lambert syndrome even though it is a form of MG.
A client has Guillain-Barré syndrome. Which interdisciplinary health care team members does the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in this client? Select all that apply. A) Certified hospital chaplain B) Family members C) Dietitian D) Occupational therapist (OT), Social worker
ANS B, C, D The nurse plans to collaborate with family members, the dietician, and OT to help prevent pressure ulcers in the client with GBS. Family members would help to develop interventions to prevent these ulcers, because the family will mostly likely be directly involved in the client's care. Malnutrition puts the client at greater risk for pressure ulcers, so the dietitian must be included as well. The OT can provide assistive devices that will help prevent ulcers.The certified hospital chaplain and the social worker can assist with providing additional psychosocial support but would not be involved with direct prevention of ulcers. The social worker would also assist with the discharge plan and reintegration into the community. CORRECT Dietitian
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A) Chills B) Generalized malaise C) Headache with stiff neck D) Temperature of 99° F (37° C)
ANS C Headache with stiff neck Immediate evaluation is needed when a client with GBS receiving IVIG complains of a headache with stiff neck. This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy.Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy must be stopped.
A client arrives in the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A) Bell's palsy B) Guillain-Barré syndrome (GBS) C) Myasthenia gravis (MG) D) Trigeminal neuralgia
ANS C Myasthenia gravis (MG) The nurse expects the client with these signs/symptoms will be tested for MG. Sudden-onset ptosis, diplopia, and dysphagia are classic signs/symptoms of MG. Laboratory studies and a cholinesterase inhibitor test (e.g., Tensilon challenge test) most likely will be done to confirm the diagnosis.Signs/symptoms of Bell's palsy include facial paralysis; the face appears masklike and sags. Signs/symptoms of GBS typically begin in the legs and spread to the arms and upper body. Trigeminal neuralgia is characterized by sharp, intense facial pain that is usually not associated with sensory or motor deficits.
A client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A) Calls the Rapid Response Team (RRT) to intubate B) Instructs the client on how to cough effectively C) Raises the head of the bed to 45 degrees D) Suctions the client
ANS C Raises the head of the bed to 45 degrees The nurse's first action for a client with an exacerbation of GBS who now has dyspnea is to raise the head of the bed to 45 degrees. The head of the client's bed must be elevated to allow for increased lung expansion. This action helps improve the client's ability to breathe.Calling the RRT for intubation may be necessary if dyspnea is severe or oxygen saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the client on how to cough effectively is not the priority in this case. The client would be suctioned as needed but cautiously to avoid vagal stimulation.
A client with new-onset Bell's palsy is being dismissed from the hospital. Which statement made by the client demonstrates a need for further teaching by the nurse? A) "I'll need artificial tears at least four times a day." B) "I will eat a soft diet." C) "My eye must be taped or patched at bedtime." D) "Narcotics will be needed for pain relief."
ANS D "Narcotics will be needed for pain relief." Mild analgesics, not narcotics, are used for pain associated with Bell's palsy.Further teaching about Bell's palsy is needed when the client says that narcotics are needed for pain. Artificial tears need to be taken at least 4 times a day and taping the affected eye at night protects the cornea from drying out and potentially ulcerating. Drying out of the eyes occurs because of the eye's inability to close. Mastication is often impaired with Bell's palsy, so soft foods are indicated.
A client has returned to the unit after a thymectomy and is extubated. The client begins to report chest pain. What does the nurse do next? A) Calls the Rapid Response Team for immediate intubation B) Gives sublingual nitroglycerin (Nitrostat) C) Increases the intravenous (IV) rate D) Informs the surgeon immediately
ANS D Informs the surgeon immediately When a postoperative thymectomy client complains of chest pain, the nurse's next step is to call the surgeon right away. The client's chest pain could be a symptom of a hemothorax or pneumothorax and must be reported to the surgeon immediately.It may be beneficial to notify the Rapid Response Team based on hospital policy; however this would not be the next step. Intubation is not absolutely indicated in this case. The cause of chest pain is unclear but likely related to the thymectomy; therefore, sublingual nitroglycerin would not be beneficial. Increasing the intravenous (IV) rate is not indicated.
A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A) Inability to tolerate everyday activities related to severe fatigue B) Inability to communicate verbally related to vocal weakness C) Inability to care for self-related to muscle weakness D) Potential for aspiration related to difficulty with swallowing
ANS D Potential for aspiration related to difficulty with swallowing The client problem that has the highest priority for a client with MG is the risk for aspiration due to difficulty swallowing. The potential for aspiration is the highest priority client problem because the client's ability to maintain airway patency is compromised.Although important, an inability to tolerate everyday activities, an inability to communicate verbally related to vocal weakness, and an inability to care for oneself related to muscle weakness are not the nurse's highest priority.
The nurse is teaching a client about taking a new prescription for pyridostigmine. Which statements by the nurse indicate correct information about this drug? (Select all that apply.) a. "Avoid opioids and other sedating drugs when taking this medication." b. "Report increased mucous secretions and sweating immediately to the primary health care provider." c. "Take the prescribed medication after meals to increase intestinal absorption." d. "Avoid taking antibiotics, especially neomycin, while on this medication" e. "Maintain the exact same dose of this medication every day."
ANS: A, B, D Choice A and D are correct due to potential drug-drug interactions with pyridostigmine. Choice B suggests possible cholinergic crisis which can occur if the dose of the medication is too high. The drug should be taken before meals to increase muscle tone needed to chew, swallow, and digest food. The drug dosing may vary depending on how the client is performing each day.
The nurse is caring for a client diagnosed with Guillain Barre syndrome. Which assessment findings require nursing action? (Select all that apply.) a. Blood pressure of 80/42 b. A respiratory rate of 24 c. Shallow breathing pattern d. A peripheral oxygen saturation (Spo2) of 85% e. Diminished breath sounds in all lung fields
ANS: A, C, D, E All choices except B are abnormal assessment findings that can occur in clients with this disease. A respiratory rate of 24 is slightly elevated but does not require nursing action.
The nurse is caring for a client with trigeminal neuralgia. Which patient problem is the priority for the nurse? a. Facial twitching b. Problems with communication c. Ptosis and diplopia d. Severe facial pain
ANS: D The client with trigeminal neuralgia (TN) has severe burning or sharp pain that is worsened by facial movement or eating. While the client may also experience facial twitching, managing pain is the priority problem. The client with TN usually does not have problems with communication or facial paralysis.
