PrepU questions for MS 3 1st exam
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are. What would be the instructor's best answer?
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the degree of blockage, and the availability of collateral circulation."
A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?
"Eat small amounts of bland, soft foods frequently."
A nurse is instructing the spouse of a client who suffered a stroke about the use of eating devices the client will be using. During the teaching, the spouse starts to cry and states, "One minute he is laughing, and the next he's crying; I just don't understand what's wrong with him." Which statement is the best response by the nurse?
"Emotional lability is common after a stroke, and it usually improves with time."
The nurse is taking health history from a client admitted to rule out Guillain-Barre syndrome (GBS). An important question to ask related to the diagnosis is which of the following?
"Have you experienced any viral infections in the last month?"
Which statement by the 20-year-old female client diagnosed with Myasthenia Gravis indicates the client understands the discharge teaching?
"I can have children, but I will have to see my neurologist during my pregnancy."
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life."
A 30-year-old was diagnosed with Amyotrophic Lateral Sclerosis (ALS). Which statement by the client would indicate a need for more teaching from the nurse?
"My children are at greater risk to develop this disease."
Amyotrophic Lateral Sclerosis (ALS) need more teaching:
"My children are at greater risk to develop this disease."
A client recently experienced a stroke with accompanying left-sided paralysis. His family voices concerns about how to best interact with him. They report the client doesn't seem aware of their presence when they approach him on his left side. What advice should the nurse give the family?
"The client is unaware of his left side. You should approach him on the right side."
After having a stroke, a patient has cognitive deficits. What are the cognitive deficits the nurse recognizes the patient has as a result of the stroke? Select all that apply.
- Poor abstract reasoning - Decreased attention span - Short- and long term memory loss
Most drugs used to treat Myasthenia Gravis act by preventing the destruction of acetylcholine at the neuromuscular junction. Myasthenia Gravis occurs when antibodies attack the nicotinic acetylcholine receptors at the neuromuscular junction leading to muscle weakness. You're educating a patient about the pathophysiology of Myasthenia Gravis. A patient with Myasthenia Gravis will be eating lunch at 1200. It is now 1000 and the patient is scheduled to take Pyridostigmine. At what time should you administer this medication so the patient will have the maximum benefit of this medication?
1 hour before the patient eats (at 1100)
A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?
1 to 3 days
Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome (GBS), would not be manifested by which of the following?
20/20 vision
A patient is admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the doctor ordered tPA. The nurse knows to give this drug no later than what time?
4:00 p.m.
Research has shown that patient adherence to prescribed regimens is generally low, especially when the patient will have to follow the regimen for a long time. Which of the following individuals would most likely benefit from health education that emphasizes adherence?
A 52-year-old woman who has a new diagnosis of Multiple Sclerosis
Which patient below is MOST at risk for developing a Cholinergic Crisis?
A patient with Myasthenia Gravis reports taking too much of their anticholinesterase medication.
In Myasthenia Gravis, the nurse knows that there is a decrease in the number of receptor sites of which neurotransmitter?
Acetylcholine
Myasthenia Gravis, an autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the voluntary muscles. Prostigmine is prescribed for patients with Myasthenia Gravis. It increases muscular contraction. Myasthenia Gravis (MG) occurs when antibodies attack which receptor sites?
Acetylcholine
A client's low prothrombin time (PT) was attributed to low vitamin K levels and the client's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize?
Adequate nutrition
During a Tensilon test to determine if a patient has Myasthenia Gravis (MG), 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 hospitalized with a severe exacerbation of Myasthenia Gravis. When administering medications to this client, what is a priority nursing action?
Administer medications at exact intervals ordered.
A client with Myasthenia Gravis (MG) is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements?
Antibodies are removed from the plasma.
Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?
Apraxia
The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?
B12
Which of the following is the most common side effect of tissue plasminogen activator (tPA)?
Bleeding
Which is a symptom of hemochromatosis?
Bronzing of the skin
The provider diagnoses the patient as having had an ischemic stroke. The etiology of an ischemic stroke would include which of the following?
Cardiogenic emboli
You're providing teaching to a group of patients with Myasthenia Gravis. Which of the following is not a treatment option for this condition?
Cholinesterase medications
Which meal option would be the most appropriate for a patient with Myasthenia Gravis?
Clam chowder with mashed potatoes
The client with Myasthenia Gravis is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention?
Client's BP is 94/60 and AP is 112
A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met?
Closely monitor intake and output.
Progressive weakness in a client diagnosed with Myasthenia Gravis is related to which component of the disease process?
Defects in the transmission of nerve impulses to the skeletal muscles
The physician has ordered a somatosensory evoked responses (SERs) test for a patient for whom the nurse is caring. The nurse is justified in suspecting that this patient may have a history of what type of neurologic disorder?
Demyelinating disease/ Multiple sclerosis
The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies?
Drink liquid iron preparations with a straw.
The nurse is completing an assessment on a client with Myasthenia Gravis. Which of the following historical recountings provides the most significant evidence regarding when the disorder began?
Drooping eyelids
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?
Eating calf's liver with a glass of orange juice
The nurse is preparing the client for an acetylcholinesterase inhibitor test to rule out Myasthenia Gravis (MG). Which is the priority nursing action?
Ensure atropine is readily available.
The nurse is caring for a patient who is hospitalized with an exacerbation of Multiple Sclerosis. To ensure the patient's safety, what nursing action should be performed?
Ensure that suction apparatus is set up at the bedside Feedback: Because of the patient's risk of aspiration, it is important to have a suction apparatus at hand
The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?
Erythrocytes that are microcytic and hypochromic
The nurse is caring for a client with aphasia. Which strategy will the nurse use to facilitate communication with the client?
Establishing eye contact
Most patients diagnosed with Multiple Sclerosis (MS) have a relapsing-remitting course. A patient is admitted to the medical unit with exacerbation of Multiple Sclerosis. When assessing this patient, the nurse has the patient stick out her tongue and move it back and forth. What is the nurse assessing?
Function of the hypoglossal nerve /12th cranial nerve
A client with Guillain-Barre syndrome (GBS) cannot swallow and has paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following is related to the intake of nutrients?
Gag reflex and bowel sounds
The nurse is teaching a patient with Guillain-Barr syndrome about the disease. The patient asks how he can ever recover if demyelination of his nerves is occurring. What would be the nurse's best response?
Guillain-Barr spares the Schwann cell, which allows for remyelination in the recovery phase of the disease.
A 37-year-old woman with Multiple Sclerosis is married and has three children. The nurse has worked extensively with the woman and her family to plan appropriate care. What is the nurse's most important role with this patient?
Help the patient develop strategies to implement treatment regimens.
The patient with Myasthenia Gravis is complaining about dealing with muscle weakness. Which of the following could the nurse do for this patient?
Help the patient form a plan to take medications on time
A patient has a probable diagnosis of polycythemia vera. The nurse reviews the patient's lab work for which diagnostic indicator?
Hematocrit of 60%
Which disturbance results in loss of half of the visual field?
Homonymous hemianopsia
Which term will the nurse use when referring to blindness in the right or left half of the visual field in both eyes?
Homonymous hemianopsia
The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication regimen, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based on research data that shows the most important risk factor for stroke is:
Hypertension
The nurse is teaching a client about Myasthenia Gravis. Which statement, if made by the patient indicates the need for further teaching?
I can take ibuprofen to help with pain that may occur with spasms
Which statement by the female client diagnosed with Myasthenia Gravis indicates the client needs more discharge teaching?
I will not have a menstrual cycle of this disease."
Which of the following client statements indicates a need for further teaching?
I will soak in a warm bath every day
A diagnostic test has determined that the appropriate diet for the client with a left cerebrovascular accident (CVA) should include thickened liquids. Which of the following is the priority nursing diagnosis for this client?
Impaired Swallowing
A nurse is planning the care of a 28-year-old woman hospitalized with a diagnosis of Myasthenia Gravis. What approach would be most appropriate for the care and scheduling of diagnostic procedures for this patient?
In the morning, with frequent rest periods
You are the clinic nurse caring for a patient with a recent diagnosis of Myasthenia Gravis. The patient has begun treatment with pyridostigmine bromide (Mestinon). What change in status would most clearly suggest a therapeutic benefit of this medication?
Increased muscle strength Feedback: The goal of treatment using pyridostigmine bromide is improvement of muscle strength and control of fatigue.
Which is a contraindication for the administration of tissue plasminogen activator (t-PA)?
Intracranial hemorrhage
You are the nurse caring for a client with Guillain-Barré syndrome (GBS). The client also has ascending paralysis. Knowing the complications of the disorder, what should you keep always ready at the bedside?
Intubation tray and suction apparatus
A patient who has suffered a stroke begins having complications regarding spasticity in the lower extremity. What ordered medication does the nurse administer to help alleviate this problem?
Lioresal (Baclofen)
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?
Low ferritin level concentration
Guillain-Barr syndrome is an autoimmune attack on the peripheral nerve myelin. A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume
The nurse is planning care for a client with Guillain-Barre syndrome (GBS). The priority client outcome would be which of the following?
Maintains effective respirations and airway clearance
A nurse is assessing a client who has Myasthenia Gravis and is taking neostigmine. Which of the following findings should indicate to the nurse that the client is experiencing adverse effects of the medication?
Miosis (pupillary constriction)
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?
Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential
You're a home health nurse providing care to a patient with Myasthenia Gravis. Today you plan on helping the patient with bathing and exercising. When would be the best time to visit the patient to help with these tasks?
Morning
A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate?
Neurologic involvement
The nurse is assessing a client with Multiple Sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?
Nystagmus
A nurse in an acute care facility is preparing to admit a client who has Myasthenia Gravis. Which of the following supplies should the nurse place at the client's bedside?
Oral-nasal suction equipment Feedback: A client who has Myasthenia Gravis is at risk of aspiration due to progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.
A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron?
Orange juice
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
Pallor, tachycardia, and a sore tongue
A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure?
Peripheral edema
While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?
Platelet count, prothrombin time, and partial thromboplastin time
A patient with a new diagnosis of Amyotrophic Lateral Sclerosis (ALS) is overwhelmed by his diagnosis and the known complications of the disease. How can the patient best make known his wishes for care as his disease progresses?
Prepare an advance directive Feedback: Patients with Amyotrophic Lateral Sclerosis (ALS) are encouraged to complete an advance directive or living will to preserve their autonomy in decision-making.
Which of the following is the first-line therapy for Myasthenia Gravis (MG)?
Pyridostigmine bromide (Mestinon)
During lunch, a bedridden client with Myasthenia Gravis experiences increased dysphagia. What nursing action is the priority?
Raise the HOB immediately
The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take?
Refuse to administer the blood
The geriatric advanced practice nurse (APN) is doing client teaching with a client who has had a cerebrovascular accident (CVA) and the client's family. One concern the APN addresses is a potential for falls related to the CVA and resulting muscle weakness. What would be most important for the APN to include in teaching related to this concern?
Remove throw rugs and electrical cords from home environment.
The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome (GBS). On which of the following areas will the nurse focus most heavily?
Respiratory
The nurse is caring for a patient with Multiple Sclerosis (MS). The patient tells the nurse the hardest thing to deal with is fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?
Resting in an air-conditioned room whenever possible
A client on your unit is scheduled to have intracranial surgery in the morning. Which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?
Restrict fluids before surgery.
The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for?
Schilling test
The nurse is caring for a patient having a hemorrhagic stroke. What position in the bed will the nurse maintain this patient?
Semi-Fowler's
A nurse is providing teaching to a client who has a new diagnosis of Myasthenia Gravis (MG). Which of the following pieces of information should the nurse include?
Set an alarm to ensure medication dosages are taken on time
While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:
Severe headache and early change in level of consciousness
The wife of a client diagnosed with Myasthenia Gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
Sit down and allow the wife to ventilate her feelings to the nurse.
The nurse is participating in a health fair for stroke prevention. Which will the nurse say is a modifiable risk factor for ischemic stroke?
Smoking
Which is a modifiable risk factor for transient ischemic attacks and ischemic strokes?
Smoking
What nursing intervention is appropriate for a client with receptive aphasia?
Speak slowly and clearly
The client with Myasthenia Gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective?
The client is able to feed self independently.
The client is being evaluated to rule out Myasthenia Gravis & being administered the Tensilon test. Which response to the test indicates the client has Myasthenia Gravis?
The client shows a marked improvement in muscle strength Feedback: Clients with Myasthenia Gravis show a significant improvement in muscle strength that lasts approximately 5 minutes when Tensilon (edrophonium chloride) is injected.
When should the nurse plan the rehabilitation of a patient who is having an ischemic stroke?
The day the patient has the stroke
A patient has a diagnosis of Multiple Sclerosis. The nurse is aware that neuromuscular disorders such as Multiple Sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
The maximal volume of air exhaled from the point of maximal inspiration
The neurologist is conducting a Tensilon test (Edrophonium) at the bedside of a patient who is experiencing unexplained muscle weakness, double vision, difficulty breathing, and ptosis. Which findings after the administration of Edrophonium would represent the patient has Myasthenia Gravis?
The patient experiences improved muscle strength.
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?
The patient needs to be assessed for Multiple Sclerosis.
You are the nurse caring for a young mother who has a longstanding diagnosis of Multiple Sclerosis (MS). She was admitted to your unit with a postpartum infection 3 days ago. You are planning to discharge her home when she has finished 5 days of IV antibiotic therapy. With what information would it be most important for you to provide this patient?
The same information you would provide to a patient without a chronic condition
Which referral is appropriate for the client in the late stages of Myasthenia Gravis?
The speech therapist.
The client w/ Myasthenia Gravis is admitted to the emergency room with a sudden exacerbation of motor weakness. Which assessment data indicates the client is experiencing Cholinergic Crisis?
The tensilon test does not show improvement in the client's muscle strength
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
Thrombolytic therapy has a time window of only 3 hours.
A nurse is caring for a client with thalassemia who is being transfused. What is the nurse's role during a transfusion?
To closely monitor the rate of administration
Guillain Barré syndrome is an autoimmune attack on myelin, a complex substance that covers nerves. The nurse caring for a patient diagnosed with Guillain-Barr syndrome is planning care with regard to the clinical manifestations associated this syndrome. The nurse's communication with the patient should reflect the possibility of what sign or symptom of the disease?
Vocal paralysis Feedback: Guillain-Barr syndrome is a disorder of the vagus nerve. Clinical manifestations include vocal paralysis, dysphagia, and voice changes (temporary or permanent hoarseness).
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for?
a noncontrast computed tomography (CT) scan
Hemophilia A is the most common of the three types of hemophilia. What is diminished in the less serious form of hemophilia A, known as von Willebrand's disease?
amount and quality of factor VIII
A nurse is reading a journal article about stroke and the underlying causes associated with this condition. The nurse demonstrates understanding of the information when identifying which subtype of stroke as being due to atrial fibrillation?
cardio embolic
While caring for clients who have suffered neurologic deficits from causes such as cerebrovascular accident and closed head injury, an important nursing goal that motivates nurses to offer the best care possible is preventing:
complications.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the health care provider in the emergency department. Which is the origin of the client's symptoms?
impaired cerebral circulation
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg.
A physician has ordered home health and physical therapy for an older adult who will be discharged home following an acute stroke. The nurse's discharge teaching should include instructions about:
reporting specific signs and symptoms to the physician, discharge medications, and dietary concerns.
Myasthenia Gravis (MG) statements:
● "My eyelids droop, and I see double everything." ● "I must take my medications on time every day, or I could have problems." ● Significant other: Discuss how to perform the Heimlich maneuver.
A nurse is caring for a client who has Myasthenia Gravis (MG) and has developed drooping eyelids. Which of the following actions should the nurse take?
● Apply lubricating eye drops ● Tape eyes closed at night
The client diagnosed with Myasthenia Gravis is admitted with an acute exacerbation. Which interventions should the nurse implement?
● Assist the client to turn and cough every two (2) hours. ● Place the client in a high or semi-Fowler's position. ● Plan meals to promote medication effectiveness.
The parents of a client intubated due to the progression of Guillain-Barré syndrome (GBS) ask whether their child will die. What is the best response by the nurse?
"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
A nurse is teaching a client who was recently diagnosed with Myasthenia Gravis. Which statement should the nurse include in her teaching?
"This disease doesn't cause sensory impairment"
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 ability to perform ADLs may be the key to reentry into the community
Which interventions would be recommended for a client with dysphagia? Select all that apply.
- Assist the client with meals - Test the gag reflex before offering food of fluids - Allow ample time to eat
A nurse is beginning a physical assessment of a client who was recently diagnosed with Multiple Sclerosis (MS). Which of the following findings should the nurse expect?
- Ataxia - Areas of paresthesia - Involuntary eye movement
Which of the following are assessment findings associated with thrombocytopenia? Select all that apply.
- Bleeding gums - Epistaxis - Hematemesis
Guillain-Barré syndrome (GBS) manifestations:
- Blindness - Bulbar weakness - Inability to swallow
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.
- Blood loss - Abnormal erythrocyte production - Destruction of normally formed red blood cells
A nurse assesses a client diagnosed with megaloblastic anemia. Which clinical findings will the nurse most likely find? Select all that apply.
- Jaundice - Ulcerated corners of the mouth - Concave nails
A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply.
- Neutrophil count 1200/microlite - Hemoglobin 7 g/dL - Platelets 35,000 microliters
Which surgical procedure should the nurse anticipate the client with Myasthenia Gravis undergoing to help prevent the s/s of the disease process?
A thymectomy
The client is diagnosed with Myasthenia Gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
Administer the medication 30 minutes prior to meals.
Which term refers to the failure to recognize familiar objects perceived by the senses?
Agnosia
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?
Aplastic anemia
A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?
Creatinine level of 6 mg/100 mL
A patient diagnosed with Myasthenia Gravis has been hospitalized to receive plasmapheresis for a myasthenic exacerbation. The nurse knows that the course of treatment for plasmapheresis in a patient with Myasthenia Gravis is what?
Determined by the patient's response
After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider?
Diastolic pressure of 110 mm Hg
The nurse is assessing a client newly diagnosed with Myasthenia Gravis (MG). 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 (GBS). Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds
Signs and symptoms of Myasthenia Gravis:
● Ptosis ● Diplopia ● Restlessness ● Slurred speech ● Respiratory failure
A client with Guillain-Barré syndrome (GBS) has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?
"The paralysis caused by this disease is temporary."
The nurse is preparing to provide care for a patient diagnosed with Myasthenia Gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
A lower motor neuron lesion Feedback: Myasthenia Gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower neuron lesion at the myoneural junction. It is not a genetic disorder.
A nurse has instructed a client with Myasthenia Gravis regarding risk factors for Myasthenia Gravis exacerbations. Which client statement indicates a need for further teaching?
A nurse instructs a client who has Myasthenia Gravis about home care and the risk factors that can exacerbate the disease.
You are teaching your patient diagnosed with Myasthenia Gravis about treatments. Which of the following statements, if made by the patient indicates the need for further teaching?
A thymectomy is a removal of my thymus gland and will show some immediate relieving of my symptoms
Your patient diagnosed with Myasthenia Gravis begins taking Mestinon. During the first week, the dosage is changed frequently. While the dosage is being adjusted, the nurse's priority intervention is to:
Administer the medication exactly on time
A community health nurse is giving an educational presentation about stroke and heart disease at the local senior citizens' center. What nonmodifiable risk factor for stroke should the nurse cite?
Advanced age
A nurse is providing education to a community group about ischemic strokes. One group member asks if there are ways to reduce the risk for stroke. Which of the following is a risk factor that can not be modified?
Advanced age
Which of the following is a disease in which there is a loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem?
Amyotrophic lateral sclerosis (ALS)
Which of the following is the most common hematologic condition affecting elderly patients?
Anemia
If warfarin is contraindicated as a treatment for stroke, which medication is the best option?
Aspirin
The client is diagnosed with Myasthenia Gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
Assess for excess salivation and abdominal cramps.
The patient with Myasthenia Gravis arrives to the clinic and states that he is experiencing nausea and diarrhea. His blood pressure is 125/85, HR 70, Temp 100.0, R 19, O2 97%. What is the nursing priority?
Assess for signs of infection
A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?
Assesses the hemoglobin level
Which nursing intervention is the priority for a client in a Myasthenic Crisis?
Assessing respiratory effort
Which of the following, if left untreated, can lead to an ischemic stroke?
Atrial fibrillation
A nurse in an emergency department is caring for a client who has Myasthenia Gravis and is in a Cholinergic Crisis. Which of the following medications should the nurse plan to administer?
Atropine
You're preparing to help the neurologist with conducting a Tensilon test. Which antidote will you have on hand in case of an emergency?
Atropine
A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?
Auditory agnosia
The nurse caring for a patient in ICU diagnosed with Guillain-Barr syndrome should prioritize monitoring for what potential complication?
Autonomic dysfunction Feedback: Based on the assessment data, potential complications that may develop include respiratory failure and autonomic dysfunction.
A nurse is teaching a client who has Amyotrophic Lateral Sclerosis (ALS) about a new prescription for riluzole (Rilutek). Which of the following instructions should the nurse give the client?
Avoid consuming alcoholic beverages
The nurse is caring for a client with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which postoperative finding would cause the nurse the most concern?
Difficulty swallowing
The nurse is caring for a client with external bleeding. What is the nurse's priority intervention?
Direct pressure
The client diagnosed with Myasthenia Gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
Discuss ways to help prevent choking episodes
Amyotrophic Lateral Sclerosis (ALS), diagnostic tests:
Electromyography (EMG).
After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client?
Elevating the head of the bed to 30 degrees
Which of the following statements reflects nursing management of the patient with expressive aphasia?
Encourage the patient to repeat sounds of the alphabet.
Aneurysm rebleeding occurs most frequently during which time frame after the initial hemorrhage?
First 12 hours
From which direction should a nurse approach a client who is blind in the right eye?
From the left side of the client
A stroke victim is experiencing memory loss and impaired learning capacity. The nurse knows that brain damage has most likely occurred in which lobe?
Frontal
The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
Guillain-Barr syndrome Feeback: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, Myasthenia Gravis, and Guillain-Barr syndrome.
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?
Iron deficiency anemia
The nurse is caring for a client admitted with a stroke. Imaging studies indicate an embolus partially obstructing the right carotid artery. What type of stroke does the nurse know this client has?
Ischemic
A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?
Keeping the client in one position to decrease bleeding
A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?
Lack of deep tendon reflexes
Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat?
Lamb and peaches
What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?
Left visual field deficit
A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
Left-sided cerebrovascular accident (CVA)
The nurse's role in the management of polycythemia vera is primarily that of an educator. Choose the best health promotion advice that a nurse could give.
Participate in regular phlebotomy procedures to decrease blood viscosity.
A patient with Guillain-Barr syndrome has experienced a sharp decline in vital capacity. What is the nurses most appropriate action?
Prepare to assist with intubation Feedback: For the patient with Guillain-Barr syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate.
Your patient has just been diagnosed with Myasthenia Gravis. Which of the following orders should be questioned?
Procaine (Novocain) SQ stat to reduce pain in lower limb
A nurse is planning care for a client who experienced a stroke in the right hemisphere of his brain. What should the nurse do?
Provide close supervision because of the client's impulsiveness and poor judgment.
The critical care nurse is admitting a patient in Myasthenic Crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this patient?
Providing ventilatory assistance
The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?
Psychosis, disorientation, delirium, insomnia, and hallucinations
Which ocular or facial signs/ symptoms should the nurse expect to assess for the client diagnosed with Myasthenia Gravis?
Ptosis & diplopia
The nurse is performing an initial assessment on a client who is admitted to rule out Myasthenia Gravis (MG). Which of the following findings would the nurse expect to observe?
Ptosis and diplopia
A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?
Transient ischemic attack
Which of the following is the chief cause of intracerebral hemorrhage (ICH)?
Uncontrolled hypertension
A client is hospitalized with Guillain-Barré syndrome (GBS). Which nursing assessment finding is most significant?
Uneven, labored respirations
The nurse is developing a plan of care for a patient with Guillain-Barr syndrome. Which of the following interventions should the nurse prioritize for this patient?
Using the incentive spirometer as prescribed Feedback: Respiratory function can be maximized with incentive spirometry and chest physiotherapy
The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron?
Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.
During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?
Vitamin K
A patient with Amyotrophic Lateral Sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
Impaired verbal communication Feedback: Impaired communication is an appropriate nursing diagnosis; the voice in patients with ALS assumes a nasal sound and articulation becomes so disrupted that speech is unintelligible.
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?
Increased urine output
Which of the following would be most likely given as a top nursing diagnosis for a patient experiencing a Cholinergic Crisis?
Ineffective airway clearance
A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client?
Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit
The client is experiencing a Myasthenic Crisis. Which of the following is a priority action of the following ordered actions?
Insert NG tube
An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy?
International normalized ratio greater than 2
The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see?
Right-sided paralysis
Which collab health care team member should the nurse refer the client to in the late stages of Myasthenia Gravis?
Speech Therapist
Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?
Speeds nerve impulse transmission
The nurse is providing care for a patient who has Multiple Sclerosis. The nurse recognizes the autoimmune etiology of this disease and the potential benefits of what treatment?
Stem cell transplantation
A client with respiratory complications of Multiple Sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?
Suction machine with catheters
Most patients diagnosed with Multiple Sclerosis (MS) have a relapsing-remitting course.
TRUE
The initial manifestation of Myasthenia Gravis in most patients involves the ocular muscles.
TRUE.
Which of the following tests confirms the diagnosis of Myasthenia Gravis (MG)?
Tensilon test
The male client diagnosed with Myasthenia Gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicates the medication is not effective?
The client cannot speak or look upward at the ceiling.
The male client with Myasthenia Gravis is undergoing plasmapheresis at the bedside. Which assessment data would warrant immediate intervention by the nurse?
The client complains of being lightheaded and dizzy.
The client diagnosed with Myasthenia Gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicates the client is experiencing a Myasthenic Crisis?
The client's symptoms improve when administering a cholinesterase inhibitor.
Amyotrophic Lateral Sclerosis (ALS): loss of motor neurons in the anterior horns of the spinal cord and motor nuclei of the lower brain stem. A nurse is providing teaching to the family of a client who has a new diagnosis of Amyotrophic Lateral Sclerosis (ALS). Which of the following findings is an early manifestation of ALS?
Weakness of the distal extremities Feedback: Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing. ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord, causing muscle wasting, spasticity, and eventually paralysis.
A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse expect?
Weakness of the lower extremities Feedback: Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.
The nurse is providing information about strokes to a community group. Which of the following would the nurse identify as the primary initial symptoms of an ischemic stroke?
Weakness on one side of the body and difficulty with speech
A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide?
Wear a medical identification bracelet.
A nurse is caring for a client admitted to the hospital with respiratory difficulty after being diagnosed with Amyotrophic Lateral Sclerosis (ALS) approximately 1 year ago. Which of the following client findings should the nurse anticipate? (Select all that apply)
● Incontinence ● Ineffective cough