Chapter 44 - Problems of the Peripheral Nervous System

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response?

"This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke." Skeletal muscle weakness extends to the ability to chew and swallow. Clients who have myasthenia gravis are at risk for aspiration during meals. Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily.

The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively?

Assess the skin surrounding the cast. The nurse assesses the skin surrounding the cast hourly for tightness, warmth, and color. If the cast is too tight, the nurse notifies the provider immediately.

A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?

Avoid large crowds and people who are ill. Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness.

The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe?

Controllable facial twitching Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking, smiling, eating, or attending to hygienic needs.

The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action?

Document the finding. Loss of motor and sensory function after complete trigeminal nerve dissection is normal. No intervention is necessary.

The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process?

Elevated acetylcholine receptor antibody levels Testing for acetylcholine receptor (AChR) antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels.

The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure?

Hypovolemia The client undergoing plasmapheresis is at risk for hypovolemia. The nurse monitors fluid status, assesses vital signs, and administers replacement fluid, as indicated.

The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?

Inability to perform the six cardinal positions of gaze The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed.

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?

Obtaining atropine sulfate Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.

A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?

Performing appropriate hand hygiene Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility.

The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action?

Prepare the client for elective intubation. Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation. The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?

Respiratory system Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client?

Suction the client to remove secretions. Atropine can cause thickening of secretions and formation of mucous plugs. The client is maintained on a ventilator during the crisis. Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important.

A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client?

Sudden onset of shortness of breath The complication to be alert for is pneumothorax or hemothorax. The nurse monitors the client for chest pain, sudden onset of shortness of breath, diminished chest wall expansion, decreased breath sounds, restlessness, and changes in vital signs.

The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered?

Tensilon test The Tensilon test in an important procedure for a client in myasthenic crisis. Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions, which enhance the manifestations of a myasthenic crisis.

A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt?

The presence of a bruit Nursing care of the client undergoing plasmapheresis includes care of the shunt. The nurse checks for bruits every 2 to 4 hours for patency. Pulse and extremity assessments do not provide information related to shunt patency. Pressure within the shunt is not tested before treatment to determine patency.

A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met?

Weight gain of 3 pounds in 1 month Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed.

The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching?

"A combination of morphine and distraction helps bring me relief right now." Typical pain from GBS often is not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects. Patient-controlled analgesia (PCA) pumps should be set with appropriate doses and limits.

A client with trigeminal neuralgia is about to undergo surgery for pain relief. The client asks, "How will this surgery relieve my pain?" How does the nurse respond?

"A small artery compressing the nerve will be relocated." In some clients, a small artery compresses the nerve as it enters the pons. By relocating this nerve, pain relief is obtained and sensation is spared.

A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)

"Do not eat a full meal for 45 minutes after taking the drug." "Seek immediate care if you develop trouble swallowing." "The dose may change frequently depending on symptoms."

A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?

"Do not use harsh chemicals on your face." The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury.

A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver?

Cardiopulmonary resuscitation (CPR) Respiratory compromise is a common occurrence with myasthenia gravis. The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home.

A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

-Cutting foods up into small bites -Thickening liquids prior to drinking Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration.

A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?

"I can scratch with a coat hanger." Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.

The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis?

"I had a viral infection about 2 weeks ago." The client with GBS often relates a history of acute illness, trauma, surgery, or immunization 1 to 3 weeks before the onset of neurologic symptoms.

The nurse is teaching a client who is receiving carbamazepine (Tegretol) for chronic trigeminal neuralgia. Which statement indicates that the client correctly understands the teaching?

"I will avoid drinking alcohol because it can add to the side effects of this medicine." Carbamazepine is thought to interfere with the transmission of pain through slow fibers. It may decrease the paroxysmal afferent impulse that causes trigeminal pain. Trigeminal disease does not cause seizures. Drowsiness, dizziness, confusion, and risk for falls are adverse effects of this medication. Alcohol consumption increases these risks; therefore the client should not drink alcohol when taking this medication.

The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching?

"I will change positions slowly." Autonomic dysfunction causes orthostatic hypotension. The client should change positions slowly to prevent orthostatic hypotension. Autonomic dysfunction can cause peripheral polyneuropathy, so the client should be taught to wear socks and shoes at all times and not to use a heating pad.

The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching?

"I will have to take things slowly for several months after I leave the hospital." Most clients make a full recovery from GBS. Recovery can take as long as 6 months to 2 years. Fatigue is a major lingering symptom for most of those diagnosed with this disorder. Clients are not permanently paralyzed. They are in an acute care environment during the acute phase of the disorder.

A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?

"MG is an autoimmune problem in which nerves do not cause muscles to contract." MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan?

"Use a thermometer to check the temperature of bath water." The client with neuropathy has loss of sensation in the lower extremities, which can predispose the client to thermal injury. The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn.

A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.)

-Acyclovir (Zovirax) -Famciclovir (Famvir) -Prednisone (Deltasone) -Valacyclovir (Valtrex) Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.

An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.)

-Advising the client to have help getting up -Consulting the provider about the drug -Placing the client on safety precautions Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider.

The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)

-Ask occupational therapy to help the client with activities of daily living. -Consult with the provider about a physical therapy consult. -Work with speech therapy to design a high- protein diet. Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy.

A client has just undergone surgery for peripheral nerve trauma. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)

-Immobilization of the affected area with a splint -Occupational therapy -Skin care, including hygiene and ointments Care for the client with peripheral nerve trauma includes immobilization before and after surgery, and skin care to prevent skin breakdown and promote healing. The client may likely require physical or occupations therapy during the recovery process.

The nurse is preparing a staff in-service program related to restless legs syndrome (RLS). Which potential risk factors of this syndrome does the nurse include? (Select all that apply.)

-Polyneuropathies -Diabetes mellitus type 2 Risk factors for RLS include a possible genetic basis, history of type 2 diabetes mellitus, advanced kidney failure, vitamin and mineral deficiencies, polyneuropathies, peripheral nerve disease, age, lack of exercise, and pinched nerve.

The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.)

-Use Standard Precautions. -Send the specimen in a sealed bag displaying a biohazard symbol. -Confirm the specimen label with the client's identification band. The Standard Precautions approach is based on the premise that a medical history and a physical examination cannot reliably identify all those infected by pathogens. Consequently, health care workers should consider all human blood and body fluids as potentially infectious and must use appropriate protective measures to prevent possible exposure. Specimens should be labeled appropriately and transported in a sealed bag displaying the biohazard symbol.

The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what?

Slowed nerve impulse transmission Demyelination leads to slowed nerve impulse transmission.

A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?

Ask the client to explain his feelings related to this disorder. Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved.

An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?

Assess the client's oxygen saturation. In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur?

Atropine sulfate Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate, causing cardiac fibrillation or arrest. Atropine sulfate is an anticholinergic drug.

The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client?

Collaborate with the physical therapist. The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse collaborates with the physical therapist in teaching the client energy conservation techniques. T

A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?

Inadequate airway Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process?

Increased cerebrospinal fluid (CSF) protein level A lumbar puncture is performed to evaluate the CSF. An increased CSF protein level without increased cell count is a distinguishing feature of GBS.

A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best?

Instruct the client on a magnesium supplement. Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement.

The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client?

Progressive, ascending weakness and paresthesia The most common clinical pattern of Guillain-Barré syndrome is the ascending variety. Weakness and paresthesia begin in the lower extremities and progress upward.

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?

The immune system destroys the myelin sheath. In Guillain-Barré syndrome, the immune system destroys the myelin sheath, causing segmental demyelination. Nerve impulses are transmitted more slowly but remain in place. Antibodies are not developed.