Neuro 3

The nurse is caring for a patient with myasthenia gravis who had a thymectomy. The patient demonstrates restlessness and reports chest pain and shortness of breath. What are the priority nursing interventions? SATA

B. Administer oxygen C. Raise the head of the bed 45 degrees E. Notify the Rapid response team

The patient with MS has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication?

B. Check the patient's gag reflex and ability to swallow.

A patient with myasthenia gravis demonstrates a weak cough. Auscultation of the lungs reveals coarse crackles throughout the lung fields. The nurse identifies the patient is unable to cough effectively enough to clear the airway of secretions. Which intervention is best for this patient?

B. Chest physiotherapy

Which strategies should be incorporated in the plan of care to provide emotional support for a patient with Guillain-barre syndrome? SATA

B. Encourage the patient to verbalize feelings C. Teach the patient and family about the condition D. Explain all procedures and tests E. Allow regularly scheduled rest periods. F. Assess previous coping skills.

A patient with myasthenia gravis and the nurse are having a long discussion about plans for the future. After an extended conversation, what does the nurse anticipate will occur in this patient?

B. Voice may become weaker or exhibit a nasal twang.

Which interventions is appropriate to protect a patient with myasthenia gravis from corneal abrasions?

C. Apply lubricant gel and shield to the eyes at bedtime.

The nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium is used to establish the diagnosis. An increase in which factor will confirm the diagnosis?

D. Muscle strength

A nurse is caring for a client in the home who has the diagnosis of amyotrophic lateral sclerosis (ALS). Which position should the nurse recommend that the client assume after eating?

D. Semi-fowlers

An LPN, under the RN's supervision, is assigned to provide nursing care for a client with guillain-Barre syndrome. What observation should the LPN be instructed to report immediately?

D. Shallow respirations and decreased breath sounds.

To assess the hypoglossal nerve, what will the nurse ask the patient to do?

D. Stick the tongue straight out

The home health nurse sees in the patient's record that he takes riluzole. Which question is the nurse most likely to ask?

A. When were you first diagnosed with amyotrophic lateral sclerosis.

The nurse is teaching a patient with MS and her family about her exercise program. Which points must the nurse include? SATA

A. ROM exercises are an important component C. Increased body temperature can lead to increased fatigue E. Stretching and strengthening exercises will be part of your program.

The RN notes that a client with myasthenia gravis has an elevated temperature, and increased heart rate, and a rise in BP and is incontinent of urine and stool. What is the nurse's best action at this time?

B. Notify the health care provider immediately.

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first?

B. Raise the head of the bed.

The nurse is reviewing the admission and history notes for a patient admitted for guillain-barre syndrome. Which medical condition is most likely to be present before the onset of GBS?

B. Recent bacterial infection

A recently hospitalized client with MS is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

B. Space activities throughout the day

Although an adverse reaction during the Tensilon challenge test is considered rare, which medication should be readily available to give as an antidote in case a patient should experience complications?

C. Atropine sulfate

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? SATA

A. Respiratory depression C. Decreased blood pressure E. High-pitched gurgling bowel sounds

A client with MS tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time?

1. Fatigue

The nurse reads in the patient's chart that he has myasthenia gravis with bulbar involvement. Which intervention is the nurse most likely to use?

A. Administer medication 45-60 minutes before meals

Which disorder could have a similar clinical presentation to multiple sclerosis?

A. Amyotrophic lateral sclerosis

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

A. Aspiration

The nurse is caring for a patient who has a shunt for plasmapheresis. Which interventions related to the shunt does the nurse perform?

A. Assess for bruit or thrill every 2-4 hours.

The nurse is monitoring a patient with Guillain-barre syndrome underlying plasmapheresis. The patient reports dizziness and has a heart rate that has dropped to 48 beats per minute. The nurse notifies the primary care provider. Which order does the nurse anticipate?

A. Atropine IV push

For a patient with GBS, what is the expected and desired outcome of plasmapheresis?

A. Decreases the symptoms

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occured in the past, but they resolved and no medical attention was sought. Which questions does the nurse ask to assess whether the symptoms may be associated with MS? SATA

B. "Do you have a persistent sensitivity to temperature?" C. "Do you ever have slurred speech or trouble swallowing?" E. "Has anyone in your family been diagnosed with MS?" F. "Do you have spasms at night that wake you from your sleep?"

A patient has been newly diagnosed with Guillian-barre syndrome. The nurse is teaching the patient and family about this condition. Which statement bt the family indicates a need for additional teaching?

B. "He'll never be able to walk again."

A patient with myasthenia gravis has been referred to a surgeon for a procedure that may improve the patient's symptoms. Which brochure would the nurse prepare for the patient?

B. "How to prepare for your surgical thymectomy."

A patient with MS is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug?

B. "We need to teach you how to monitor your pulse rate because this drug can cause a slow heart rate."

The nurse is performing teaching for the family of a patient with myasthenia gravis about fatigue and activities of daily living. Which statement by a family member indicates a need for additional teaching?

B. "We should do hygienic care for her to avoid undue frustration and fatigue."

The nurse is caring for a patient newly diagnosed with myasthenia gravis. The nurse is alert for complications related to both myasthenic crisis and cholinergic crisis. What is the priority nursing assessment for this patient?

B. Assess respiratory status and function

A nurse is caring for a client with the diagnosis of Guillain-Barre syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention?

B. Suction the client's oropharynx

The nurse is assessing a patient with a diagnosis of Guillain-Barre syndrome. Which signs and symptoms would the nurse expect to observe? SATA

B. Sudden onset of weakness in the legs E. Double vision F. Uncoordinated movements

What can be one cause of a cholinergic crisis?

B. Too many anticholinesterase drugs

A client with myasthenia gravis asks the nurse why the disease has occurred. What pathology underlies the nurse's reply?

C. A decreased number of functioning acetylcholine receptor sites

What is the priority nursing assessment for a patient with myasthenia gravis?

C. Ability to chew and swallow

A patient with guillain-barre syndrome is receiving IV immunoglobulin. The nurse monitors for which major potential complication of this drug therapy?

C. Anaphylaxis

The patient with MS states she is bothered by diplopia. Which intervention does the nurse expect to implement?

C. Application of an eye patch alternating from eye to eye every few hours.

A home care nurse is counseling a client with amyotrophic lateral sclerosis (ALS). What information should the nurse include in the discussion? SATA

A. Space activities throughout the day D. Anticipate the use of alternative ways to communicate.

The nurse is caring for a patient who has undergone plasmapheresis. Which laboratory tests must the nurse monitor in relation to this therapy? SATA

A. Complete blood count B. Coagulation studies E. Electrolytes

An ambulatory female client with relapsing-remitting MS is to receive every-other day injections of interferon beta- 1a. Which adverse effects should the nurse explain may occur when taking this medication?

A. Depression B. Constipation C. Flu-like symptoms D. Increased heart rate

Which clinical findings does the nurse anticipate a client with an exacerbation of MS to experience? SATA

A. Double vision D. Scanning speech

The patient with Guillain-barre syndrome is at risk for aspiration. Which precautions must the nurse initiate to prevent aspirations? SATA

A. Elevate the head of the bed at least 45 degrees. B. Assess for dysphagia prior to giving oral fluids or medications D. Have suctioning equipment available at the bedside.

A patient is supected of having myasthenia gravis, and a tensilon challenge test has been ordered. What does the nurse do to prepare the patient for the test?

A. Ensure that the patient has a patent IV access.

The nurse is reviewing the cerebral spinal fluid results for a patient with probable Guillain-barre syndrome, who has been having symptoms for several weeks. Which abnormal finding is most likely to be seen at this time?

A. Increase in CSF protein level

What is the priority expected outcome in a patient with guillian-barre syndrome?

A. Maintain airway patency and gas exchange

A patient with guillain-barre syndrome is identified as having poor dietary intake secondary to dysphagia. A feeding tube is prescribed. How does the nurse monitor this patient's nutritional status?

C. Review weekly serum prealbumin level

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" What information about what the client can anticipate should be incorporated into the nurse's response?

C. Chronic illness with exacerbations and remissions.

The nurse asks a patient with GBS to smile, frown, whistle, and drink from a straw. Which cranial nerve is the nurse assessing?

C. Cranial Nerve VII

The patient with GBS is immobile and shows evidence of malnutrition. What is the priority concern related to immobility and nutritional status?

C. Risk of pressure ulcers

What diagnostic test is used to differentiate a cholinergic crisis from a myasthenic crisis?

C. Tension challenge testing

A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client?

C. Diplopia

During shift report, the nurse hears that a patient with Guillain-barre syndrome has a decrease in vital capacity that is less than two-thirds normal, and there is a progressive inability to clear and cough up secretions. The HCP has been notified and is coming to evaluate the patient. What intervention is the nurse prepared to implement for this patient?

C. Elective intubation

A patient is admitted for a probable diagnosis of guillain-barre syndrome but needs additional diagnostic testing for confirmation. Which test does the nurse anticipate will be ordered for this patient?

C. Electrophysiologic study

A patient tells the nurse, "I have the symptoms of MS, and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employ first?

C. Encourage the to verbalize feelings and frustrations.

A patient is receiving a cholinesterase inhibitor drug for the treatment of myasthenia gravis. What is a nursing implication for this medication that relates to patient safety?

C. Feed meals 45-60 minutes after administration

An ambulatory patient has sought treatment for symptoms of guillain-barre syndrome. IV immunoglobulin therapy has been prescribed. Which precaution does the nurse expect with this therapy?

C. IV immunoglobulin is slowly infused when it is started.

The nurse is caring for a patient recently diagnosed and admitted with myasthenia gravis. During the morning assessment, the nurse notes some abnormal findigns. Which symptoms is cause for the greatest concern?

C. Inability to swallow

What does the nurse understand that the clients with myasthenia gravis, Guillain-Barre syndrome, and amyotrophic lateral sclerosis (ALS) share in common?

C. Increased risk of respiratory complications

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis?

C. Ineffective coughing

The nurse is planning activities for a patient with myasthenia gravis. Which factor does the nurse consider to promote self-care, yet prevent excessive fatigue?

C. Medication times

A client with guillain-Barre syndrome is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced UAP.

C. Weigh the client before and after the procedure.

The nurse is caring for a patient receiving cholinesterase inhibitor drugs for myasthenia gravis. Which symptoms does the nurse immediately report to the health care provider?

C. dyspnea and difficulty swallowing

A client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring?

D. Ascending weakness.

A patient with Guillain-barre syndrome has been intubated for respiratory failure. The nurse must suction the patient. In assessing the risk for vagal nerve stimulation, what does the nurse closely monitor the patient for?

D. Bradycardia

A patient with myasthenia gravis experienced a cholinergic crisis and is currently being maintained on a ventilator. The patient received several 1 mg doses of atropine IV. What does the nurse closely monitor for?

D. Development of mucus plugs

The Nurse is performing patient and family teaching about myasthenia gravis and medications. What important information does the nurse give during the teaching session?

D. Drugs containing morphine or sedatives can increase muscle weakness.

The most common symptoms of myasthenia gravis are related to involvement of the levator palpebrae or extraocular muscles. Which assessment technique would the nurse use?

D. Face the patient and instruct to open and close the eyelids.

What is the nursing concept that underlies the etiology and the pathophysiology of Guillain-barre syndrome?

D. immunity

A client with myasthenia gravis continues to become weaker despite treatment with neostigmine. What reason should the nurse identify for the health care provider's prescription for edrophonium?

A. Rule out cholinergic crisis

A patient with myasthenia gravis has generalized weakness and fatigue and is limited in the ability to perform activities of daily living. Which nursing action is best to help this patient avoid excessive fatigue?

A. Schedule activities after medication administration

During the shift report, the nurse learns that a patient with myasthenia gravis deteriorated toward the end of the shift and the health care was called. Tensilon challenge test indicated that the patient was having a myasthenic crisis. What is the priority problem for this patient?

A. Potential for inadequate oxygenation

The nurse is assessing a patient with myasthenia gravis. Which manifestations can the nurse expect to observe? SATA

A. Ptosis B. Diplopia D. Ocular palsies F. Fatigue

The nurse is caring for a patient who is slowly recovering GBS with ascending paralysis. Which sign of physical recovery would the nurse expect to see first?

A. Respiratory effort improves.

The nurse is teaching the patient and family about the factors that predispose the patient to episodes of exacerbation of myasthenia gravis. Which factors does the nurse mention? SATA

A. Infection B. Stress C. Sedatives E. Enema F. Strong cathartics

A patient with myasthenia gravis is experiencing impaired communication related to weakness of the facial muscles. Which interventions are best in assisting the patient to communicate with the staff and family? SATA

A. Instruct the patient to speak slowly C. Ask yes or no questions D. Use system of eye blinking E. Have patient use a picture, letter, or word board.

A patient with myasthenia gravis reports having difficulty climbing stairs, lifting heavy objects, and raising arms over the head. What is the underlying pathophysiology of this patient's symptoms?

A. Limb weakness is more often proximal

The patient has Guillain-barre syndrome with ascending paralysis. What would the nurse expect to observe?

A. Motor weakness that starts in legs and then spreads to arms and upper body.

The nurse is reviewing medication orders for a patient with myasthenia gravis. The patient is scheduled to receive pyridostigmine on a daily basis. What does the nurse expect regarding this drug?

A. Noting daily dosage change related to presenting symptoms

The nurse is caring for a patient with myasthenia gravis. What problem does does the nurse expect the patient to have?

A. Patient has more trouble with mobility when he is fatigued.

To maintain mobility for the patient with guillain-barre syndrome, which intervention is best for the nurse to delegate to the UAP?

A. Perform passive range of motion every 2-4 hours.

Which statement by a client with MS indicates to the nurse that the client needs further teaching?

B. I will take a hot bath to help relax my muscles.

What nursing intervention is anticipated for a client with Guillain-Barre syndrome?

B. Maintaining ventilator settings to support respiration

A patient with myasthenia gravis is having a difficulty maintaining an adequate intake of food and fluid because of difficulty chewing and swallowing. Which task for this patient is best to delegate to UAP?

Perform daily weights

The nurse has provided teaching to the husband of a 33-year-old woman who was recently diagnosed with MS. Which statement by the patient's husband indicates he needs additional teaching on the course of the illness?

D. "As the disease progresses, she could have intermittent short-term memory loss."

A patient with myasthenia gravis is experiencing a cholinergic crisis. What is the major concern when caring for this patient?

respiratory failure

What is considered a positive diagnostic finding a Tensilon challenge test?

B. Within 30-60 seconds after receiving the cholinesterase inhibitor, there is increased muscle tone that lasts 4-5 minutes.

A client with MS is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?

B. swimming

A client with myasthenia gravis has been receiving neostigmine and asks about its action. What information about its action should the nurse consider when formulating a response?

B. Blocks the action of cholinesterase.