neuro

...34.A nurse is preparing a client newly diagnosed with multiple sclerosis for discharge home from a rehabilitation center. The client has been prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which instruction will the nurse include in a teaching plan for the client?

"Avoid people with colds." The client should be taught to avoid individuals with any type of upper respiratory illness because these medications are immunosuppressive.

Which statement from the client with Guillain-Barré syndrome indicates that teaching about disease progression was effective?

"I may need a ventilator until the paralysis goes away." GBS is characterized by ascending paralysis that is not permanent. During the acute phase, if the paralysis affects the intercostal muscles, the client may require mechanical ventilation until the paralysis begins to descend. The client will not require a mechanical ventilator or wheelchair after recovery from the acute phase of the disease. There is no relationship of exacerbation of GBS to being around other people

Nursing activities for a client with ALS and family include helping themThe nurThe Nurse cautions clients with ALS and their families to be aware that (Select all that apply)

...activities should be spaced throughout the day. muscle weakness may cause a risk for injury. Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder.

Nursing activities for a client with ALS and family include helping them a. decide on an acceptable level of care early in the course of the disease. b. determine if they want to share the diagnosis to allow genetic testing. c. incorporate nonpharmacologic pain control techniques in the plan of care. d. plan for extensive rehabilitation after exacerbations.

ANS: A Disease management in ALS includes topics such as tube feedings and mechanical ventilation. Planning for an acceptable level of care should begin early in the disease, before a crisis occurs. Of course, decisions should be re-evaluated occasionally as the client's wishes may changes with their experiences with the disease. ALS is not a genetically-acquired disorder. Pain control is usually not an issue in the disease, and as the disease is relentlessly progressive (rather than characterized by remissions and exacerbations), extensive rehabilitation is not utilized.

he nurse cautions clients with ALS and their families to be aware that (Select all that apply) a. activities should be spaced throughout the day. b. clients experience incontinence, an early cause of falling. c. cognition will usually decline late in the disease. d. muscle weakness may cause a risk for injury.

ANS: A, D Safety is a prime concern with ALS (and with any degenerative neurologic disorder). Muscle weakness is progressive, leading to increased risk of falls. Some interventions to prevent this include spacing activities throughout the day, conserving energy, avoiding extremes of hot and cold, and using assistive devices such as canes or wheelchairs. Clients with ALS usually do not experience incontinence and cognition remains intact for the duration of the disorder.

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should a. attempt to institute bowel-training activities. b. provide the client with small, frequent feedings. c. obtain an order for intermittent catheterization. d. orient the client to his or her surroundings frequently.

ANS: B The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness.

When a client is admitted to the hospital with Guillain-Barré syndrome (GBS), the most important assessment the nurse should make is for a. decreasing alertness. b. respiratory difficulty. c. seizure activity. d. urinary retention.

ANS: B The two most dangerous features of GBS are respiratory muscle weakness and autonomic neuropathy involving both the sympathetic and the parasympathetic systems.

12. A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with a. admission and administration of IV corticosteroids. b. an increased dose of anticholinesterase drugs. c. bolus doses of atropine titrated to effect. d. rest and increased sleep.

ANS: B With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other options is used to treat a myasthenic crisis.

16.Which nursing intervention is aimed at reducing muscle weakness in the client with myasthenia gravis?

Assisting the client with activities of daily living (ADLs) The hallmark of myasthenia gravis is muscle weakness that increases with fatigue. The nurse provides assistance with ADLs to prevent fatigue. The nurse also collaborates with the physical therapist in teaching the client energy conservation techniques.

A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?

Assisting the patient with active range of motion (ROM)

15.The client suspected to have myasthenia gravis is about to undergo the Tensilon (edrophonium chloride) test. Which drug will the nurse have available for complications of this test?

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.

21.A client with myasthenia gravis is preparing for discharge. Which instructions will be included in the education of 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.

Which conditions or factors in an adult woman diagnosed with MS are most likely to have contributed to this health problem?

Heritability or genetic factors Having a first-degree relative with MS increases the individual's risk of developing the disease. There is a higher prevalence of certain genes in populations with higher rates of MS.

7.The nurse monitors for which complication in the client with Guillain-Barré syndrome who is undergoing plasmapheresis?

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

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include

IV infusion of immunoglobulin (Sandoglobulin). Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

d.35.The early manifestations of amyotrophic lateral sclerosis (ALS) and MS are somewhat similar. Which clinical feature of ALS distinguishes it from MS?

Impairment of respiratory muscles In ALS, there is progressive muscle atrophy until a flaccid quadriplegia develops. Eventually, there is involvement of the respiratory muscles, which leads to respiratory compromise.

A nurse is caring for a client with Guillain-Barré syndrome who has been admitted to the intensive care unit. During the last 2 hours, 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?

Preparing the client for elective intubation Deterioration in vital capacity to less than 15 mL/kg and the inability to clear secretions are indications for elective intubation.

3.The nurse correlates which clinical manifestation of Guillain-Barré syndrome as the most common?

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 notes in the patient's medical history that the patient has a positive Romberg test. Which nursing diagnosis is appropriate?

Risk for falls related to dizziness or weakness Rationale: A positive Romberg test indicates that the patient has difficulty maintaining balance with the eyes closed.

A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug?

a. Diazepam (Valium) b. Interferon β1b (Betaseron) c. Lioresal (Baclofen) d. Methylprednisolone (Solu-Cortef) ANS: B Drugs used to treat exacerbations in ambulatory clients include Interferon β1b, Interferon β1a (Avonex), and glatiramer acetate (Copaxone). Diazepam and lioresal could be used to treat spasticity, while steroids are used for acute relapses.

A client with MS is being taught self-care measures to prevent constipation. The nurse would realize goals for teaching had been met when the client states he/she will avoid

a. a high-fiber diet. b. citrus fruits. c. laxatives. d. stool softeners. ANS: C A high-fiber diet, bulk formers, and stool softeners are useful for maintaining stool consistency. Explain that laxatives and enemas should be avoided because they lead to dependence.

The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is

a. damage occurs primarily to the dendrites and oligodendrites. b. once damaged, myelin cannot regenerate at all. c. plaques occur anywhere in the white matter of the central nervous system (CNS). d. Schwann cells are destroyed slowly but relentlessly. ANS: C Although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord.

The nurse formulates the following nursing diagnosis for a client with MS: Impaired Physical Mobility related to muscle weakness. Useful interventions the nurse could plan include

a. encouraging long naps or rest periods. b. encouraging strengthening exercises for affected muscles every 4 hours. c. having the client perform ROM exercises at least two times daily. d. performing all the activities of daily living (ADLs) for the client. ANS: C Range-of-motion exercises should be performed at least twice daily.

When teaching the patient with newly diagnosed multiple sclerosis (MS) about the disease, the nurse explains that?

autoimmune processes cause gradual destruction of the myelin sheath of nerves in the brain and spinal cord. Rationale: The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission. Although MS susceptibility does appear to be inherited, the disease is not congenital because the interaction of multiple factors precipitates MS development. Impulse transmission along nerve fibers is slowed. Antibodies to acetylcholine receptors do not cause MS.

The nurse formulates the following nursing diagnosis for a client with MS: Impaired Physical Mobility related to muscle weakness. Useful interventions the nurse could plan include

having the client perform ROM exercises at least two times daily. Range-of-motion exercises should be performed at least twice daily.

A client with MS is being taught self-care measures to prevent constipation. The nurse would realize goals for teaching had been met when the client states he/she will avoid

laxatives. A high-fiber diet, bulk formers, and stool softeners are useful for maintaining stool consistency. Explain that laxatives and enemas should be avoided because they lead to dependence.

When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should

question the patient about any leg weakness or spasm.

A patient with multiple sclerosis (MS) has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to

teach the patient how to use the Credé method. Rationale: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Which statement indicates that the client has a correct understanding about recovery from Guillain-Barré syndrome?

"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 this disorder.

When planning care for a patient with MS who has a nursing diagnosis of risk for activity intolerance related to extremity weakness secondary to stress, the most appropriate patient goal is

"The patient will complete ADLs without fatigue." Rationale: Because the nurse has identified the patient's problem as activity intolerance, a patient goal that indicates improvement in activity tolerance, such as ability to accomplish ADLs without fatigue, is most appropriate. The other goals are appropriate for nursing diagnoses such as ineffective coping, impaired physical mobility, and inadequate nutritional intake.

a.A nurse has instructed the client with myasthenia gravis to take drugs on time and to eat meals 45 to 60 minutes after taking the 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." The 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.

A client with MG began to experience a sudden worsening of her condition with difficulty in breathing. The nurse explains that this complication of MG is usually initially treated with

...an increased dose of anticholinesterase drugs. With myasthenic crisis, if an increase in the dosage of the anticholinesterase drug does not improve the weakness, endotracheal intubation and mechanical ventilation may be required. None of the other

Which statement by the client indicates understanding of treatment for pain related to Guillain-Barré syndrome?

..."A combination of morphine and distraction seems to help bring me relief right now." Typical pain from GBS is often not relieved by medication other than opiates. Distraction, repositioning, massage, heat, cold, and guided imagery may enhance the opiate effects.

A nurse is performing an assessment on a client who is suspected of having MG. The complaint made by the client that reflects a manifestation commonly seen in clients with this disease is

..."By the end of the day, my eyelids usually are drooping." The primary feature of MG is increasing weakness with sustained muscle contraction. After a period of rest the muscles regain their strength. Muscle weakness is greatest after exertion or at the end of the day. Ocular manifestations are most common, with ptosis or diplopia occurring in a majority of clients.

The client with relapsing-remitting multiple sclerosis asks why continuous treatment with interferon beta-1a (Avonex) is necessary. Which is the nurse's best response?

..."This medication will help decrease the number and severity of relapses." Interferon beta-1a is a biologic response modifier that is given IM once weekly to decrease the number and severity of relapses.

In discussing advanced directives, a client with ALS states that he does not want to be placed on a mechanical ventilator. Which is the nurse's best response?

..."What would you like to be done if you begin to have difficulty breathing?" ALS is an adult-onset upper and lower motor neuron disease, characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must include in the advanced directives what is to be done when breathing is no longer possible without intervention.

The nurse assesses for which clinical manifestation in the client with MS of the relapsing-remitting type?

...Attacks becoming increasingly frequent The classic picture of relapsing-remitting MS is characterized by increasingly frequent attacks.

A client with multiple sclerosis has been treated for 6 months with mitoxantrone (Novantrone). Which clinical manifestation alerts the nurse to an adverse effect of this medication?

...Crackles in the lungs Mitoxantrone (Novantrone) is an antineoplastic agent that can cause cardiotoxicity when used for long periods. Adverse effects are congestive heart failure and dysrhythmias.

The nurse correlates which pathophysiologic process to the client with a diagnosis of multiple sclerosis (MS)?

...Damage to the myelin sheath causes an inflammatory response. In MS, the myelin sheath is damaged, leading to an inflammatory response.

Which physical assessment finding does the nurse expect to observe in a client with myasthenia gravis?

...Difficulty or 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.

In evaluating laboratory data, the nurse correlates which results with the diagnosis of myasthenia gravis?

...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.

A client presents with an acute exacerbation of multiple sclerosis. Which drug will the nurse be prepared to administer?

...Methylprednisolone (Medrol) Methylprednisolone is the drug of choice for acute exacerbations of the disease.

Which clinical manifestations would serve to alert the nurse to the early onset of MS?

...Nystagmus and ataxia Early signs and symptoms of MS include changes in motor skills, vision, and sensation.

The client with myasthenia gravis develops a sudden increase in weakness, accompanied by an increase in heart rate from 76 to 100 beats/min and an increase in blood pressure from 122/72 to 152/82 mm Hg. Which conclusion will the nurse reach from these findings?

...The client is experiencing myasthenic crisis. The client in myasthenic crisis experiences a rise in heart rate and blood pressure as well as an increase in muscle weakness.

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

...The immune system destroys the myelin sheath.

The nurse recognizes which pathophysiologic change in the client diagnosed with myasthenia gravis?

...There is a defect in the transmission of nerve impulses to the skeletal muscles. The major pathologic defect in myasthenia gravis is that nerve impulses are not transmitted to skeletal muscles at the neuromuscular junction

A patiA patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome

...is due to an immune reaction that attacks the covering of the peripheral nerves.

When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to

...perform necessary physically demanding activities in the morning. Rationale: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for in situations where corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

A 24A 29 -year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is

...performing constant evaluation of respiratory function.

The nurse reminds a group of students about the major component of pathophysiology in multiple sclerosis (MS), which is

...plaques occur anywhere in the white matter of the central nervous system (CNS). Although plaques may occur anywhere in the white matter of the CNS, the areas most commonly involved are the optic nerves, cerebrum, and cervical spinal cord.

A client with advanced ALS is admitted to the hospital. Because of manifestations that are common in clients with ALS, the nurse should

...provide the client with small, frequent feedings. The course of the disease is relentlessly progressive. Cognition, as well as bowel and bladder sphincters, remains intact. The client may be malnourished because of dysphagia. Encourage small, frequent, high-nutrient feedings. The nurse should assess for aspiration and choking. A feeding tube may be considered during the course of the illness.

When a client is admitted to the hospital with Guillain-Barré syndrome (GBS), the most important assessment the nurse should make is for

...respiratory difficulty. The two most dangerous features of GBS are respiratory muscle weakness and autonomic neuropathy involving both the sympathetic and the parasympathetic systems.

A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals the patient should avoid

...talking on the phone. Rationale: The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals. The other activities will not affect the muscles used for chewing and swallowing.

The client with myasthenia gravis in cholinergic crisis has been treated with atropine. Which nursing intervention is a priority for this client?

Suctioning the client 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.

20.Immediately after undergoing a thymectomy, the nurse monitors for which complication in the client with myasthenia gravis?

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 change in vital signs. The other symptoms are not likely to occur or are not related to the removal of the thymus.

4.In reviewing laboratory data on a client, the nurse correlates which findings with Guillain-Barré syndrome (GBS)?

Increased cerebral spinal fluid (CSF) protein level without increased cell count 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.The nurse prioritizes which nursing diagnosis for the client admitted with Guillain-Barré syndrome?

Ineffective Breathing Pattern related to skeletal muscle weakness The most common cause of death for the client with Guillain-Barré syndrome is complications from respiratory compromise. Airway and breathing problems should receive priority nursing diagnoses.

A client is being treated in the clinic for an exacerbation of multiple sclerosis. The nurse would anticipate administering which drug?

Interferon 1b (Betaseron) Drugs used to treat exacerbations in ambulatory clients include Interferon 1b, Interferon 1a (Avonex), and glatiramer acetate (Copaxone). Diazepam and lioresal could be used to treat spasticity, while steroids are used for acute relapses.

Which neurologic test or procedure requires the nurse to determine whether an informed consent has been obtained from the client before the test or procedure?

Lumbar puncture for cerebrospinal fluid (CSF) sampling A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive.

dA 28-year-old woman has had multiple sclerosis (MS) for 3 years and wants to have children before her disease worsens. When she asks about the risks associated with pregnancy, the nurse explains that

MS symptoms may be worse after the pregnancy. Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Pregnancy, labor, and delivery are not affected by MS.

6.A client with Guillain-Barré syndrome is undergoing plasmapheresis. The nurse determines shunt patency through which parameter?

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.

Which conditions or factors in a middle-aged woman diagnosed with Guillain-Barré syndrome are most likely to have contributed to this problem?

She 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.

A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the patient's

respiratory function.Rationale: Because the patient's respiratory insufficiency is life threatening, it will be most important to monitor respiratory function during the Tensilon test. Pupillary size and muscle strength may also be affected by the test but are not as important to monitor. LOC is not typically affected by MG, although the LOC may be affected by oxygenation in this patient.