Chapter 44 -medsurg questions
The client's spouse expresses concern that the client, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response? A. "Contact the Guillain-Barré Foundation International for resources." B. "Try inviting several people over so the client won't have to go out." C. "Let your spouse stay alone. Your spouse will get used to it." D. "This behavior is normal."
A; The Guillain-Barré Foundation International (www.gbsi.com) provides resources and information for clients and their families. The client and family should be referred to self-help and support groups for clients with chronic illness, if indicated.
The client with myasthenia gravis (MG) is receiving cholinesterase inhibitor drugs to improve muscle strength. The nurse is educating the family about this therapy. Which statement by a family member indicates correct understanding of the nurse's instruction? A. "I should call 911 if a sudden increase in weakness occurs." B. "I should increase the dose if a sudden increase in weakness occurs." C. "The medication should be taken with a large meal." D. "The medication should be taken on an empty stomach."
A; A potential adverse effect of cholinesterase inhibitors is cholinergic crisis. Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. The family member should call 911 for emergency assistance.
The nurse encourages the ventilated client with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A. Blinking for "yes" or "no" B. Moving lips to speak C. Using sign language D. Using a laptop to write
A; A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated client with GBS to communicate.
The client is being evaluated for signs associated with myasthenia crisis or cholinergic crisis. Which symptoms lead the nurse to suspect that the client is experiencing a cholinergic crisis? A. Abdominal cramps, blurred vision, facial muscle twitching B. Bowel and bladder incontinence, pallor, cyanosis C. Increased pulse, anoxia, decreased urine output D. Restlessness, increased salivation and tearing, dyspnea
A; Abdominal cramps, blurred vision, and facial muscle twitching are signs of an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs.
The client is admitted with trigeminal neuralgia for a percutaneous sterotactic rhizotomy in the morning. The client currently reports pain. What does the nurse do next? A. Administers pain medication as requested B. Ensures that the client is nothing by mouth (NPO) C. Ensures that the preoperative laboratory work is complete D. Performs a preoperative assessment
A; Addressing the client's pain is the priority nursing intervention because pain is the main symptom of trigeminal neuralgia.
The nursing instructor asks the nursing student to compare and contrast Bell's palsy and trigeminal neuralgia. Which statement by the nursing student is correct? A. "Choking, coughing, or eructation may occur in both disorders." B. "Both are disorders of the autonomic nervous system." C. "Facial twitching occurs in both disorders." D. "Both disorders are caused by the herpes simplex virus, which inflames and irritates cranial nerve V."
A; Both Bell's palsy and trigeminal neuralgia can affect cranial nerve V, which affects swallowing, chewing, and biting.
Which statement by the nursing student illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. The client's respiratory status and muscle function are affected by both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases exhibit exacerbations and remissions of their signs and symptoms. D. Demyelination of neurons is a cause of both diseases.
A; Both GBS and MG affect respiratory status and muscle function.
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.
A; Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important? a. Avoid large crowds and people who are ill. b. Check blood sugars four times a day. c. Use two forms of contraception. d. Wear properly fitting socks and shoes.
A; Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.
An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.
A; In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? a. "MG is an autoimmune problem in which nerves do not cause muscles to contract." b. "MG is an inherited destruction of peripheral nerve endings and junctions." c. "MG consists of trauma-induced paralysis of specific cranial nerves." d. "MG is a viral infection of the dorsal root of sensory nerve fibers."
A; MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.
A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care? a. "I can scratch with a coat hanger." b. "I should feel my fingers for warmth." c. "I will keep the cast clean and dry." d. "I will return to have the cast removed."
A; Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.) a. "Do not eat a full meal for 45 minutes after taking the drug." b. "Seek immediate care if you develop trouble swallowing." c. "Take this drug on an empty stomach for best absorption." d. "The dose may change frequently depending on symptoms." e. "Your urine may turn a reddish-orange color while on this drug."
ABD; Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client's urine will not turn reddish-orange while on this drug.
The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.
ABE; Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)
ACDE; Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.
The nurse is caring for a child with the beginning ascending paralysis of Guillain-Barré Syndrome. What nursing actions should be implemented in the care of this child? (Select all that apply.) A. Use play as a means of assessing the child's neurological abilities. B. Assess pulse oximetry measurements daily. C. Listen to lung sounds several times daily. D. Reposition the child every 4 hours. E. Allow the child to eat as long as the cranial nerves are intact. F. Measure each urine watching for decreasing amounts.
ACEF;
The client newly diagnosed with myasthenia gravis (MG) is being discharged, and the nurse is teaching about proper medication administration. Which statement by the client demonstrates a need for further teaching? A. "It is important to post my medicine schedule at home, so my family knows my schedule." B. "I can continue to take over-the-counter drugs." C. "An extra supply of medicine should be kept in my car." D. "Wearing a watch with an alarm will remind me to take my medicine."
B; Clients with MG should not take any over-the-counter medications without checking with their health care provider.
The nurse admits a client with suspected myasthenia gravis (MG). The nurse anticipates that the physician will request which medication to aid in the diagnosis of MG? A. Atropine B. Edrophonium chloride (Tensilon) C. Methylprednisolone (Solu-Medrol) D. Morphine sulfate
B; Edrophonium chloride (Tensilon) is used most often for testing for MG because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors.
The client with advanced Guillain-Barré syndrome (GBS) is no longer able to perform ADLs independently. Which priority problem best identifies measures to prevent pressure ulcers? A. Acute Pain related to paresthesias B. Impaired Physical Mobility related to weakness, paralysis, and ataxia C. Ineffective Airway Clearance related to immobility D. Powerlessness, Anxiety, and Fear related to the inability to perform ADLs and usual role responsibilities
B; This client problem is specific to immobility and includes techniques for the prevention of pressure ulcers.
The client has Guillain-Barré syndrome. Which interdisciplinary health care team members will the nurse plan to collaborate with to help prevent pressure ulcers related to immobility in the client with Guillain-Barré syndrome? Select all that apply. A. Certified hospital chaplain B. Family C. Dietitian D. Occupational therapist (OT) E. Social worker
BCD; The nurse should collaborate with the client's family to develop interventions to prevent complications such as pressure ulcers. The family will mostly likely be directly involved in the client's care and should be included. Malnutrition puts the client at greater risk for pressure ulcers. The dietitian should be included to collaborate in preventing pressure ulcers. The occupational therapist (OT) should be included to collaborate in preventing ulcers. The OT can provide assistive devices.
An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions
BCE; Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's gag reflex b. Cutting foods up into small bites c. Monitoring prealbumin levels d. Thickening liquids prior to drinking e. Weighing the client daily
BD; Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses the gag reflex and monitors laboratory values.
A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown
C; Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client
C; Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.
A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions
C; Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome). When explaining this disease process to the parents, which should the nurse consider? A. Paralysis is progressive, with little hope for recovery. B. The disease is inherited as an autosomal, sex-linked, recessive gene. C. Muscle function will gradually return, and recovery is possible in most children. D. The disease results from an apparently toxic reaction to certain medications.
C; Most patients regain full muscle strength. The return of function is in reverse order of onset.
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client? a. Giving antibiotics prior to treatments b. Monitoring the client's vital signs c. Performing appropriate hand hygiene d. Placing the client in protective isolation
C; Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
The client arrives to the emergency department with new-onset ptosis, diplopia, and dysphagia. The nurse anticipates that the client will be tested for which neurologic disease? A. Bell's palsy B. Guillain-Barré syndrome C. Myasthenia gravis (MG) D. Trigeminal neuralgia
C; Sudden-onset ptosis, diplopia, and dysphagia are classic symptoms of MG. Laboratory studies and a Tensilon test most likely will be done to confirm the diagnosis.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center? a. "Avoid having teeth pulled for 1 year." b. "Brush your teeth with a soft toothbrush." c. "Do not use harsh chemicals on your face." d. "Inform your dentist of this procedure."
C; The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.
The client is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention will the nurse perform first? A. Calls the Rapid Response Team to intubate B. Instructs the client on how to cough effectively C. Raises the head of the bed to 45 degrees D. Suctions the client
C; The head of the client's bed should be raised to 45 degrees because this allows increased lung expansion, which improves the client's ability to breathe.
A client with myasthenia gravis is admitted with generalized fatigue, a weak voice, and dysphagia. Which client problem has the highest priority? A. Inability to tolerate everyday activities related to severe fatigue B. Inability to communicate verbally related to vocal weakness C. Potential for aspiration related to difficulty with swallowing D. Inability to care for self related to muscle weakness
C; The potential for aspiration is the highest priority client problem because the client's ability to maintain airway patency is compromised.
Which of the following nursing diagnosis is likely to be a priority in the care of a patient with myasthenia gravis (MG)? A. Acute confusion B. Bowel incontinence C. Activity intolerance D. Disturbed sleep pattern
C; The primary feature of MG is fluctuating weakness of skeletal muscle. Bowel incontinence and confusion are unlikely signs of MG, and although sleep disturbance is likely, activity intolerance is usually of primary concern.
The nurse is caring for a client with Guillain-Barré syndrome (GBS) who is receiving immunoglobulin (IVIG). Which client finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99° F (37° C)
C; This may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy.
The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission
D; Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best? a. Advise the client to restrict fluids. b. Assess the client for signs of infection. c. Have the client add table salt to food. d. Instruct the client on a magnesium supplement.
D; Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed.
The client with new-onset Bell's palsy is being discharged. Which statement made by the client demonstrates a need for further discharge teaching by the nurse? A. "I'll need artificial tears at least four times a day." B. "I will eat a soft diet." C. "My eye must be taped or patched at bedtime." D. "Narcotics will be needed for pain relief."
D; Mild analgesics, not narcotics, are used for pain associated with Bell's palsy.
The nurse is reviewing the medication history of a client diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase inhibitor (ChE). The nurse plans to contact the physician if the client is taking which medication? A. Acetaminophen (Tylenol) B. Furosemide (Lasix) C. Ibuprofen (Advil, Motrin, others) D. Procainamide (Pronestyl)
D; Procainamide (Pronestyl) should be avoided because it may increase the client's weakness.
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met? a. Ability to chew and swallow without aspiration b. Eating 75% of meals and between-meal snacks c. Intake greater than output 3 days in a row d. Weight gain of 3 pounds in 1 month
D; Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
