Ch 64/65. MS,GB,

27. The nurse caring for a client in ICU diagnosed with Guillain-Barré syndrome should prioritize monitoring for what potential complication? A. Impaired skin integrity B. Cognitive deficits C. Hemorrhage D. Autonomic dysfunction

ANS: D Rationale: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction. Skin breakdown, decreased cognition, and hemorrhage are not complications of Guillain-Barré syndrome. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

6. The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? A. MS is a progressive demyelinating disease of the nervous system. B. MS usually occurs more frequently in men. C. MS typically has an acute onset. D. MS is sometimes caused by a bacterial infection.

ANS: A Rationale: MS is a chronic, degenerative, progressive disease of the central nervous system, characterized by the occurrence of small patches of demyelination in the brain and spinal cord. The cause of MS is not known, and the disease affects twice as many women as men. PTS: 1 REF: p. 2094 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand NOT: Multiple Choice

28. The nurse is teaching a client with Guillain-Barré syndrome about the disease. The client asks how the client can ever recover if demyelination of the nerves is occurring. What would be the nurse's best response? A. "Guillain-Barré spares the Schwann cell, which allows for remyelination in the recovery phase of the disease." B. "In Guillain-Barré, Schwann cells replicate themselves before the disease destroys them, so remyelination is possible." C. "I know you understand that nerve cells do not remyelinate, so the health care provider is the best one to answer your question." D. "For some reason, in Guillain-Barré, Schwann cells become activated and take over the remyelination process."

ANS: A Rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The cell that produces myelin in the peripheral nervous system is the Schwann cell. In Guillain-Barré syndrome, the Schwann cell is spared, allowing for remyelination in the recovery phase of the disease. The nurse should avoid downplaying the client's concerns by wholly deferring to the health care provider. PTS: 1 REF: p. 2103 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

19. The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? A. Using the incentive spirometer as prescribed B. Maintaining the client on bed rest C. Providing aids to compensate for loss of vision D. Assessing frequently for loss of cognitive function

ANS: A Rationale: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

24. The nurse is caring for a 77-year-old client with MS. The client is very concerned about the progress of the disease and what the future holds. The nurse should know that older adult clients with MS are known to be particularly concerned about what variables? Select all that apply. A. Possible nursing home placement B. Pain associated with physical therapy C. Increasing disability D. Becoming a burden on the family E. Loss of appetite

ANS: A, C, D Rationale: Older adult clients with MS are particularly concerned about increasing disability, family burden, marital concern, and the possible future need for nursing home care. Older adults with MS are not noted to have particular concerns regarding the pain of therapy or loss of appetite. PTS: 1 REF: p. 2096 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Analyze NOT: Multiple Select

33. A client diagnosed with MS has been admitted to the medical unit for treatment of an MS exacerbation. Included in the admission orders is baclofen. What should the nurse identify as an expected outcome of this treatment? A. Reduction in the appearance of new lesions on the MRI B. Decreased muscle spasms in the lower extremities C. Increased muscle strength in the upper extremities D. Decreased severity and duration of exacerbations

ANS: B Rationale: Baclofen, a g-aminobutyric acid (GABA) agonist, is the medication of choice in treating spasms. It can be given orally or by intrathecal injection. Avonex and Betaseron reduce the appearance of new lesions on the MRI. Corticosteroids limit the severity and duration of exacerbations. Anticholinesterase agents increase muscle strength in the upper extremities. PTS: 1 REF: p. 2097 NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

35. A client with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform? A. Arrange for the client to receive a low residue diet. B. Position the client upright during feeding. C. Suction the client following each meal. D. Withhold liquids until the client has finished eating.

ANS: B Rationale: Correct, upright positioning is necessary to prevent aspiration in the client with dysphagia. There is no need for a low-residue diet and suctioning should not be performed unless there is an apparent need. Liquids do not need to be withheld during meals in order to prevent aspiration. PTS: 1 REF: p. 2102 NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

3. The nurse is caring for a client with multiple sclerosis (MS). The client tells the nurse the hardest thing to deal with is the fatigue. When teaching the client how to reduce fatigue, what action should the nurse suggest? A. Taking a hot bath at least once daily B. Resting in an air-conditioned room whenever possible C. Increasing the dose of muscle relaxants D. Avoiding naps during the day

ANS: B Rationale: Fatigue is a common symptom of clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy conservation techniques, and reducing spasticity. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Basic Care and Comfort TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply NOT: Multiple Choice

4. A client with Guillain-Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action? A. Administer bronchodilators as ordered. B. Remind the client of the importance of deep breathing and coughing exercises. C. Prepare to assist with intubation. D. Administer supplementary oxygen by nasal cannula.

ANS: C Rationale: For the client with Guillain-Barré syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the client's oxygenation needs. PTS: 1 REF: p. 2104 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

18. A 33-year-old client presents at the clinic with reports of weakness, incoordination, dizziness, and loss of balance. The client 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 Babinski reflex C. Blurred vision, intention tremor, and urinary hesitancy D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs

ANS: C Rationale: 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 Babinski reflex is found in MS. Abdominal reflexes are absent with MS. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

21. The critical care nurse is caring for 25-year-old admitted to the ICU with a brain abscess. What is a priority nursing responsibility in the care of this client? A. Maintaining the client's functional independence B. Providing health education C. Monitoring neurologic status closely D. Promoting mobility

ANS: C Rationale: Vigilant neurologic monitoring is a key aspect of caring for a client who has a brain abscess. This supersedes education, ADLs, and mobility, even though these are all valid and important aspects of nursing care. PTS: 1 REF: p. 2092 NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

7. The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? A. Encourage the client to void every hour. B. Order a low-residue diet. C. Provide total assistance with all ADLs. D. Instruct the client on daily muscle stretching.

ANS: D Rationale: A client diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The client should participate in daily muscle stretching to help alleviate and relax muscle spasms. PTS: 1 REF: p. 2098 NAT: Client Needs: Health Promotion and Maintenance TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply NOT: Multiple Choice

11. The nurse planning caring for a client diagnosed with Guillain-Barré syndrome. The nurse's communication with the client should reflect the possibility of which sign or symptom of the disease? A. Intermittent hearing loss B. Tinnitus C. Tongue enlargement D. Vocal paralysis

ANS: D Rationale: Guillain-Barré syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness). Hearing deficits, tinnitus, and tongue enlargement are not associated with this disease. PTS: 1 REF: p. 2107 NAT: Client Needs: Psychosocial Integrity TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice

16. A middle-aged client has sought care from the primary provider and undergone diagnostic testing that has resulted in a diagnosis of MS. What sign or symptom is most likely to have prompted the client to seek care? A. Cognitive declines B. Personality changes C. Contractures D. Difficulty in coordination

ANS: D Rationale: The symptoms of MS most commonly reported are fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, spasticity, and pain. Cognitive changes and contractures usually occur later in the disease. PTS: 1 REF: p. 2095 NAT: Client Needs: Physiological Integrity: Physiological Adaptation TOP: Chapter 64: Management of Clients With Neurologic Infections, Autoimmune Disorders, and Neuropathies KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand NOT: Multiple Choice