CH 64 MED SURG

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist."

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS?

Apply an eye patch to the right eye.

During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information?

Bathing Toileting Eating

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

The diagnosis of multiple sclerosis is based on which test?

MRI

The most common cause of cholinergic crisis includes which of the following?

Overmedication

Which of the following is the first-line therapy for myasthenia gravis (MG)?

Pyridostigmine bromide (Mestinon)

A nurse is caring for a client who requires a wheelchair. Which piece of equipment impedes circulation to the area it's meant to protect?

Ring or donut

What education can the nurse provide for the patient that will increase the chance of success of the bowel program?

Set a daily defecation time that is within 15 minutes of the same time every day. Have an adequate intake of fiber containing foods. Have a fluid intake between 2 and 4 L/day.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium (Tensilon) test.

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium.

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following?

Approximately 60% to 75% of clients recover completely.

The physician suspects myasthenia gravis. Which drug will be used to test for this disease?

Edrophonium (Tensilon)

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Muscle weakness and hyporeflexia of the lower extremities

Which are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply.

Pain Fatigue Spasticity Depression Numbness

The client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. The nurse monitors blood chemistry test results and urinary output for

renal complications related to acyclovir therapy.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room