Ch 24 Drugs for Neuromuscular Disorders: Myasthenia Gravis, Multiple Sclerosis, and Muscle Spasms

15. The nurse is caring for a patient who has multiple sclerosis. The patient is experiencing an acute attack. Which drug does the nurse anticipate the provider will order? a. Adrenocorticotropic hormone (ACTH) b. Cyclophosphamide (Cytoxan) c. Glatiramer acetate (Copaxone) d. Interferon-B (IFN-B)

ANS: A ACTH is given to treat an acute attack of MS. Glatiramer acetate and interferon are used for remission-exacerbation states. Cyclophosphamide is given for chronic, progressive symptoms. REF: Page 342

10. A patient has symptoms that are characteristic of multiple sclerosis (MS). Which diagnostic tests are likely to be ordered to aid in the diagnosis of this patient? a. Cerebrospinal fluid (CSF) immunoglobulin G and magnetic resonance imaging (MRI) b. CSF proteins and an angiography c. Serum albumin and a computed tomography (CT) scan d. Serum anti-acetylcholine antibodies and x-rays

ANS: A Laboratory tests that may suggest MS include CSF IgG and MRI. REF: Page 330

19. The nurse is preparing to administer methocarbamol (Robaxin) to a patient who is experiencing acute muscle spasms. The nurse notes that the patient's urine has turned black. What will the nurse do? a. Administer the next dose of methocarbamol since this is a harmless side effect. b. Contact the provider to discuss changing to cyclobenzaprine (Flexeril). c. Obtain an order for a complete blood count to evaluate blood loss. d. Request an order for liver function tests since this indicates hepatotoxicity.

ANS: A Urine may turn green, brown, or black in patients taking methocarbamol, and this is a harmless side effect. There is no need to change medications or order lab tests. REF: Page 331

1. A client with myasthenia gravis is experiencing a cholinergic crisis. Which symptoms are associated with this condition? (Select all that apply.) a. Bradycardia b. Rash c. Vomiting d. Fever e. Drooling f. Weakness

ANS: A, C, E, F Bradycardia, drooling, and weakness can all occur with cholinergic crisis. REF: Page 327

17. The nurse is preparing to care for a patient who has multiple sclerosis (MS). The nurse learns that the patient receives cyclophosphamide (Cytoxan). The nurse knows that this patient is in which stage of MS? a. Acute attack phase b. Chronic, progressive phase c. End-stage phase d. Remission-exacerbation phase

ANS: B Cyclophosphamide is used to treat MS patients who are in the chronic, progressive phase. REF: Page 330

9. A patient reports weakness of the extremities and diplopia. The nurse knows that these symptoms are characteristic of which condition? a. Cerebral palsy (CP) b. Multiple sclerosis (MS) c. Myasthenia gravis (MG) d. Parkinson's disease (PD)

ANS: B Diplopia and weakness of the extremities are two symptoms of MS. CP is characterized by muscle spasticity. MG involves generalized weakness, especially of facial muscles and respiratory muscles. PD manifests as tremors and difficulty moving and walking. REF: Page 330

14. The nurse is teaching a group of nursing students about multiple sclerosis (MS). Which statement by the nurse is correct? a. "MS is characterized by degeneration of neurons and nerves in the brain and spinal cord." b. "MS is characterized by lesions or plaques on myelin sheaths of nerves." c. "MS is characterized by neuritic plaques and neurofibrillary tangles in the CNS." d. "MS is characterized by weak muscles and decreased nerve impulses caused by decreased ACh."

ANS: B MS is characterized by lesions on myelin sheaths of nerves. REF: Page 330

11. The nurse is caring for a patient who has recurrent muscle spasms. The provider has ordered metaxalone (Skelaxin) to treat the spasms. The nurse learns that the patient has a history of drug and alcohol abuse. The nurse will contact the provider to discuss switching this patient to which medication? a. Carisoprodol (Soma) b. Chlorzoxazone (Parafon forte DSC) c. Cyclobenzaprine (Flexeril) d. Methocarbamol (Robaxin)

ANS: C Cyclobenzaprine is a muscle relaxant that does not cause drug dependence. The other muscle relaxants can cause drug dependence. REF: Page 332

3. The nurse assumes care of a patient who has myasthenia gravis and notes that a dose of neostigmine (Prostigmin) due 1 hour prior was not given. The nurse will anticipate the patient to exhibit which symptoms? a. Excessive salivation b. Muscle spasms c. Muscle weakness d. Respiratory paralysis

ANS: C Neostigmine must be given on time to prevent myasthenic crisis, which is characterized by generalized, severe muscle weakness. The other symptoms are characteristic of cholinergic crisis, caused by too much medication. REF: Page 327

18. Which muscle relaxant is used in surgery as a skeletal muscle relaxant? a. Baclofen (Lioresal) b. Chlorzoxazone (Parafon forte) c. Pancuronium bromide (Pavulon) d. Methocarbamol (Robaxin)

ANS: C Pancuronium bromide is used as a depolarizing muscle relaxant during anesthesia. REF: Page 331

4. The nurse is caring for a patient who has myasthenia gravis (MG) and takes pyridostigmine bromide (Mestinon) 60 mg every 4 hours. The patient's last dose was 45 minutes prior. The nurse notes severe muscle weakness, excess salivation, fasciculations of facial muscles, and pupil constriction. The nurse will perform which action? a. Assess the patient for signs of ptosis. b. Notify the provider to discuss an order for intravenous immune globulin (IVIG). c. Obtain an order for atropine sulfate. d. Request an order for an extra dose of pyridostigmine.

ANS: C Severe muscle weakness, excess salivation, fasciculations of facial muscles, and pupil constriction are the major signs of cholinergic crisis, caused by excess pyridostigmine. The antidote is atropine, so the nurse should obtain an order to give this. Ptosis is sign of myasthenic crisis. IVIG is given to treat symptoms of MG and not used for cholinergic crisis. Giving extra pyridostigmine would increase the symptoms. REF: Page 327

2. A 40-year-old woman is diagnosed with myasthenia gravis, and her provider recommends removal of her thymus gland. She asks the nurse why this would be helpful. The nurse will explain that removal of the thymus gland may a. increase binding of acetylcholine (ACh) molecules to ACh receptors. b. increase the amount of ACh available at neuromuscular junction sites. c. reduce the number of acetylcholine receptor sites. d. reduce the autoimmune destruction of ACh receptor sites.

ANS: D Myasthenia gravis is an autoimmune disorder involving an antibody response against a subunit of the ACh receptor site. Since the thymus is involved in systemic immunity, it is thought that removing the thymus can inhibit this process. It does not increase binding of ACh molecules to receptors or increase the amount of ACh or reduce the number of ACh receptor sites. REF: Page 327

12. The nurse provides teaching to a patient who will begin taking cyclobenzaprine (Flexeril) to treat muscle spasms. Which statement by the patient indicates a need for further teaching? a. "I may experience dizziness and drowsiness when I take this drug." b. "I should not consume alcohol while taking this medication." c. "I should take this medication with food to decrease stomach upset." d. "I will take this medication for three weeks and then stop taking it."

ANS: D This medication should not be stopped abruptly. Patients may experience dizziness and drowsiness. Alcohol will compound the central nervous system sedative effects. To decrease gastrointestinal upset, the nurse should counsel the patient to take it with food. REF: Page 332

16. The nurse is performing a health history on a patient who has multiple sclerosis. The patient reports episodes of muscle spasticity and recurrence of muscle weakness and diplopia. The nurse will expect this patient to be taking which medication? a. Adrenocorticotropic hormone (ACTH) b. Cyclophosphamide (Cytoxan) c. Cyclobenzaprine (Flexeril) d. Interferon-B (IFN-B)

ANS: D This patient is showing signs of remission and exacerbation of MS symptoms. Interferon is used to treat this phase. ACTH is used for acute attacks. Cyclophosphamide is used for chronic, progressive symptoms. Cyclobenzaprine is a centrally acting muscle relaxant that is used for muscle spasms to decrease pain and increase range of motion. REF: Page 330

8. The charge nurse observes a nurse administer undiluted intravenous pyridostigmine bromide (Mestinon) at a rate of 0.8 mg/min. The charge nurse will stop the infusion and perform which action? a. Administer atropine sulfate to prevent cholinergic crisis. b. Monitor the patient closely for respiratory distress. c. Suggest that the nurse dilute the medication with colloidal fluids. d. Tell the nurse to slow the rate of infusion of the pyridostigmine.

ANS: D When given, IV pyridostigmine should be administered undiluted at a rate of 0.5 mg/min and should not be added to IV fluids. It is not necessary to administer atropine, since the patient is not symptomatic of cholinergic crisis. REF: Page 327

7. A patient exhibits ptosis of both eyes, and the provider orders edrophonium (Tensilon). The nurse notes immediate improvement of the ptosis. The nurse understands that this patient most likely has which disorder? a. Cerebral palsy b. Multiple sclerosis c. Muscle spasms d. Myasthenia gravis

ANS: D Improvement of symptoms after administration of edrophonium is diagnostic for myasthenia gravis. REF: Page 327

6. A patient experiences severe muscle weakness, and the provider orders edrophonium bromide (Tensilon). The patient begins to show improved muscle strength within a few minutes after administration of this drug. The nurse anticipates the provider will order which drug? a. Atropine sulfate b. Edrophonium bromide (Tensilon) c. Intravenous immune globulin (IVIG) d. Pyridostigmine HCl (Mestinon)

ANS: D In this case, edrophonium is used to diagnose myasthenia gravis. Since symptoms improved with the AChE inhibitor, the patient will benefit from a longer-acting AChE inhibitor such as pyridostigmine. Atropine is given for AChE inhibitor overdose. Edrophonium is very short-acting, so it will not be used for treatment. IVIG is used when other AChE inhibitors fail. REF: Page 329

13. The nurse is performing an admission assessment on a patient who has been taking carisoprodol (Soma) for 3 weeks to treat muscle spasms. The patient reports that the muscle spasms have resolved. The nurse will contact the provider to discuss a. changing to cyclobenzaprine (Flexeril). b. continuing the carisoprodol for 1 more week. c. discontinuing the carisoprodol now. d. ordering a taper of the carisoprodol.

ANS: D Muscle relaxants can cause drug dependence and should not be withdrawn abruptly. The nurse should discuss a drug taper. REF: Page 333

1. The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in this patient? a. Cardiovascular system and postural muscles b. Central nervous system (CNS), memory, and cognition c. Gastrointestinal system (GI) and lower extremity muscles d. Respiratory system and facial muscles

ANS: D Myasthenia gravis causes fatigue and muscular weakness of the respiratory system, facial muscles, and extremities. It does not directly affect the cardiovascular system, CNS, or GI systems. REF: Page 326

5. The nurse is caring for a patient who has myasthenia gravis (MG) and is receiving pyridostigmine bromide (Mestinon). The nurse notes ptosis of both eyelids and observes that the patient has difficulty swallowing. What action will the nurse perform next? a. Contact the provider to request an order for atropine sulfate. b. Contact the provider to request an order for edrophonium chloride (Tensilon). c. Report signs of cholinergic crisis to the provider. d. Report signs of myasthenic crisis to the provider.

ANS: B Overdosing and underdoing of AChE inhibitors have similar symptoms: muscle weakness, dyspnea, and dysphagia. Edrophonium may be used to diagnose MG or to distinguish between myasthenic crisis and cholinergic crisis since it is a very short-acting AChE inhibitor. When given, if the symptoms are alleviated, the cause is myasthenic crisis; if symptoms worsen, it is cholinergic crisis. Since patients can have similar symptoms, the nurse cannot report one or the other to the provider without more information. REF: Pages 327-328