Ch 69 NCLEX
The nurse has been educating a patient newly diagnosed with MS. Which of the following statements by the patient indicates an understanding of the education? a) "I will stretch daily as directed by the physical therapist." b) "The exercises should be completed quickly to reduce fatigue." c) "I should participate in non-weight-bearing exercises." d) "I will take hot tub baths to decrease spasms."
a) "I will stretch daily as directed by the physical therapist." Explanation: Hot baths are discouraged due to the risk of injury. Patients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Patients should not hurry through the exercise activity as it may increase muscle spasticity.
A patient is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). Which instruction should the nurse provide? a) "You must avoid stress and extreme fatigue, because these can trigger a relapse." b) "Your type of MS is the least common, making it difficult to manage." c) "You will have a steady and gradual decline in function." d) "You should take your medications only during times of relapse."
a) "You must avoid stress and extreme fatigue, because these can trigger a relapse." Explanation: Stress, fatigue, and temperature extremes can trigger relapses of MS. The patient should be taught to practice a healthy lifestyle, including good nutrition, adequate sleep, and management of stress. Patients taking MS medications should take their medications on a consistent and strict schedule to produce the desired effect of fewer relapses and to prevent sclerotic plaque formation on the brain and spinal cord. RRMS is characterized by states of remission and relapses. This description is consistent with primary progressive MS. RRMS is the most common type and many treatments are available.
Which of the following is the priority nursing intervention for a patient in myasthenic crisis? a) Assessing respiratory effort b) Ensuring adequate nutritional support c) Administering intravenous immunoglobin (IVIG) per orders d) Preparing for plasmapheresis
a) Assessing respiratory effort Explanation: A patient in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.
Bell's palsy is a disorder of which cranial nerve? a) Facial (VII) b) Trigeminal (V) c) Vagus (X) d) Vestibulocochlear (VIII)
a) Facial (VII) Explanation: Bell's palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière's syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.
Which of the following are the most commonly reported clinical manifestations of multiple sclerosis? Select all that apply. a) Pain b) Spasticity c) Aphasia d) Fatigue e) Depression f) Numbness
a) Pain, b) Spasticity, d) Fatigue, e) Depression, f) Numbness Explanation: The most commonly reported clinical manifestations of MS are pain, fatigue, spasticity, depression, numbness, weakness, difficulty with coordination, and loss of balance. Aphasia is not a commonly reported clinical manifestation.
Myasthenia gravis occurs when antibodies attack which receptor sites? a) Dopamine b) Acetylcholine c) Gamma-aminobutyric (GABA) d) Serotonin
b) Acetylcholine Explanation: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and GABA are not receptor sites that are attacked in myasthenia gravis.
Which of the following nursing interventions is appropriate for a patient with double vision in the right eye due to MS? a) Place needed items on the right side. b) Apply an eye patch to the right eye. c) Administer eye drops as needed. d) Exercise the right eye twice a day (BID).
b) Apply an eye patch to the right eye. Explanation: An eye patch to the affected eye would help the patient with double vision see more clearly, thus promoting safety. Exercises for the eye would not benefit the patient. Eye drops may be needed for dryness to prevent corneal abrasion but would not have any benefit for a patient with double vision. Needed items should be placed on the unaffected (left) side.
The parents of a patient intubated due to the progression of Guillain-Barré syndrome ask if their child will die. What is the best response by the nurse? a) "Once Guillain-Barré syndrome progresses to the diaphragm there is a significant decrease in surviving." b) "It's too early to give a prognosis." c) "Don't worry; your child will be fine." d) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."
d) "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." Explanation: The survival rate of Guillain-Barré syndrome is approximately 90%. The patient may make a full recovery or suffer from some residual deficits. Telling the parents not to worry is dismissing their feelings and not addressing their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.
The diagnosis of multiple sclerosis is based on which of the following tests? a) Neuropsychological testing b) Evoked potential studies c) Cerebrospinal fluid (CSF) electrophoresis d) Magnetic resonance imaging (MRI)
d) Magnetic resonance imaging (MRI) Explanation: The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.
Which is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of demyelination in the brain and spinal cord? a) Parkinson's disease b) Huntington disease c) Creutzfeldt-Jakob disease d) Multiple sclerosis (MS)
d) Multiple sclerosis (MS) Explanation: The cause of MS is not known and the disease affects twice as many women as men. Parkinson's disease is associated with decreased levels of dopamine caused by destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia. Creutzfeldt-Jakob disease is a rare, transmissible, progressive fatal disease of the CNS characterized by spongiform degeneration of the gray matter of the brain.
The nurse is preparing the patient for an acetylcholinesterase inhibitor test to rule out myasthenia gravis. Which of the following is the priority nursing action? a) Document the results. b) Ensure atropine is readily available. c) Assess facial weakness 5 minutes after injection. d) Administer edrophonium chloride (Tensilon) per orders.
b) Ensure atropine is readily available. Explanation: Atropine should be available to control the side effects of Tensilon. The atropine should be available before the administration of Tensilon. Assessing facial weakness and documenting the results occur after the administration of Tensilon; therefore, they are not the priority interventions.
A nurse is caring for a patient diagnosed with Guillain-Barré syndrome. The patient states, "It's getting harder to take a deep breath." Which of the following actions by the nurse is most appropriate? a) Assess lung sounds. b) Call the physician and prepare for intubation. c) Explain the progression of the syndrome. d) Encourage the patient to cough.
b) Call the physician and prepare for intubation. Explanation: The progression of Guillain-Barré syndrome leads to neuromuscular respiratory failure in a large portion of the people affected. Changes in vital capacity and negative inspiratory force are usually key indicators to be monitored for early intervention. The nurse should be alert to the earliest signs that a patient may be heading toward respiratory failure. Explaining the progression of the syndrome will not change the potential need for mechanical ventilation due to respiratory failure. Because the respiratory failure is caused by neurologic changes, assessing the lung sounds, although appropriate, is not the highest priority of the patient's complaint. Encouraging the patient to cough will not change the progression of the syndrome.