EAQ N4510 MS & MG Summer 2020

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? A. Aspiration B. Dehydration C. Nutritional imbalance D. Impaired communication

A. Aspiration Rationale: Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life. While nutrition and fluid intake will be adversely affected by dysphagia, dehydration and nutritional imbalance are not the priority. Dysphagia is difficulty swallowing and does not affect communication.

A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? A. "I avoid use of a straw to drink liquids." B. "I will take a hot bath to help relax my muscles." C. "I plan to use an incontinence pad when I go out." D. "I may be having a rough time now, but I hope tomorrow will be better."

B. "I will take a hot bath to help relax my muscles." Rationale: The nurse needs to address the hot baths to correct this misconception. Hot baths tend to increase symptoms and may result in burns because of decreased sensation. All the rest are correct and do not require teaching. Using a straw gives the client less control of liquid intake, which may lead to aspiration. Although a bladder regimen to maintain control is preferable, the use of pads can avoid embarrassment. The disease does have periods of remission and exacerbation.

Steroid therapy is prescribed for a client with common signs and symptoms of multiple sclerosis. In response to the steroid therapy, what symptom does the nurse expect to decrease? A. Emotional lability B. Muscular contractions C. Pain in the extremities D. Episodes of vision loss

D. Episodes of vision loss Rationale: Steroids decrease the inflammatory process around the optic nerve, thus improving vision; visual impairment is the most common physiological manifestation of multiple sclerosis. Steroids are associated with increased emotional lability. Steroids are not effective in easing muscle contractions. Pain in the extremities is not common unless spasms are present; steroids do not relieve spasms.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? A. Narrowed airways B. Impaired immunity C. Ineffective coughing D. Viscosity of secretions

C. Ineffective coughing Rationale: Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

A client with myasthenia gravis improves and is discharged from the hospital. The discharge medications include pyridostigmine bromide 10 mg every 6 hours. The nurse evaluates that the drug regimen is understood when the client makes which statement? A. "I will take the medication on an empty stomach." B. "I need to set an alarm so I take the medication on time." C. "It will be important to check my heart rate before taking the medication." D. "I should monitor for an increase in blood pressure after taking the medication."

B. "I need to set an alarm so I take the medication on time." Rationale: Pyridostigmine is a vital drug that must be taken on time; a missed or late dose can result in severe respiratory and neuromuscular consequences or even death. Pyridostigmine should be taken with a small amount of food to prevent gastric irritation. It is unnecessary to take the pulse rate before taking pyridostigmine. Pyridostigmine may cause hypotension, not hypertension, which is a sign of cholinergic crisis.

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? A. Brief exaggeration of symptoms B. Prolonged symptomatic improvement C. Rapid but brief symptomatic improvement D. Symptomatic improvement of only the ptosis

C. Rapid but brief symptomatic improvement Rationale: Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. A. Using Credé maneuver B. Using an indwelling catheter C. Using anticholinergic medications D. Monitoring and restricting fluid intake to 800 mL daily E. Monitoring for and reporting signs of urinary tract infection

A & E Rationale: Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with multiple sclerosis. Early recognition and treatment of infection is important to decrease the risk of exacerbation in the client with multiple sclerosis. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties as concentrated urine increases the risk of urinary tract infection.

An ambulatory client with relapsing-remitting multiple sclerosis is to receive every-other-day injections of interferon beta-1a. What adverse effects does the nurse explain may occur when taking this medication? Select all that apply. A. Depression B. Constipation C. Flulike symptoms D. Increased heart rate E. Decreased perspiration

A, B, C, D Rationale: Central nervous system effects include depression that may lead to suicide attempts. Gastrointestinal side effects include constipation, diarrhea, vomiting, and abdominal pain. Interferon immune modifier causes flulike symptoms, such as fever, muscle aches, and lethargy. Drugs for increased heart rate include side effects such as tachycardia, palpitations, and hypertension. An integumentary response to this drug is sweating, not lack of perspiration (anhidrosis).

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. A. Double vision B. Problems with cognition C. Difficulty swallowing saliva D. Intention tremors of the hands E. Drooping of the upper eyelids F. Nonintention tremors of the extremities

A, C, E Rationale: Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

A client exhibits blurred and double vision and muscular weakness, and diagnostic tests are prescribed. The client is informed that a diagnosis of multiple sclerosis (MS) has been made. The client becomes visibly upset. How should the nurse respond? A. "That must have really shocked you. Tell me what the healthcare provider told you about it." B. "You should see a psychiatrist who will help you cope with this overwhelming news." C. "Don't worry; early treatment often alleviates symptoms of the disease." D. "You should be glad that we caught it early so it can be cured."

A. "That must have really shocked you. Tell me what the healthcare provider told you about it." Rationale: The response "That must have really shocked you. Tell me what the healthcare provider told you about it" acknowledges the effect of the diagnosis on the client and explores what is known. There is no evidence of ineffective coping, so a referral to a psychiatrist is not necessary. The statement "Don't worry; early treatment often alleviates symptoms of the disease" provides false reassurance. The statement "You should be glad we caught it early so it can be cured" does not address the client's current emotional state, and it is inaccurate; MS is a chronic autoimmune disease.

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? A. "You don't feel able to make a decision at this time?" B. "Have you spoken to your fiancé about your feelings?" C. "Your fiancé loves you and I'm sure still wants to marry you." D. "These are your feelings now, but don't decide until you feel better and can cope."

A. "You don't feel able to make a decision at this time?" Rationale: The response "You don't feel able to make a decision at this time?" reflects the client's concern and provides an opportunity for further verbalization while indicating the nurse's understanding. The response "Have you spoken to your fiancé about your feelings?" changes the emphasis to the fiancé's opinion and asks a direct question, which closes off communication. The response "Your fiancé loves you and I'm sure still wants to marry you" is false reassurance that belittles the client's concerns. The response "These are your feelings now, but don't decide until you feel better and can cope" gives advice and cuts off further exploration of the client's feelings.

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride test. To treat a common complication associated with the test, the nurse will have what drug available? A. Atropine B. Phenytoin C. Neostigmine D. Diphenhydramine

A. Atropine Rationale: Atropine, an anticholinergic, always should be available to treat a cholinergic crisis (sudden, severe episode of muscle weakness that affects breathing and swallowing) should the edrophonium chloride test trigger this response. Phenytoin is an anticonvulsant that will not avert or treat complications resulting from a Tensilon test. Neostigmine is a cholinergic that has the same action as edrophonium chloride; it is contraindicated if a cholinergic crisis occurs. Diphenhydramine is an antihistamine that will not avert complications or effectively treat a cholinergic crisis.

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? A. Encourage the client to rest for short periods. B. Continue the bath while supporting the client's arms. C. Gradually increase the client's activity level each day. D. Administer a dose of pyridostigmine bromide.

A. Encourage the client to rest for short periods. Rationale: Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins. Continuing the bath while supporting the client's arms and gradually increasing the client's activity level each day will aggravate the fatigue; activity and rest should be delicately balanced to prevent fatigue. Administering a dose of pyridostigmine bromide cannot be done without a healthcare provider's prescription; rest usually will alleviate the fatigue.

The healthcare provider prescribes neostigmine for a client with myasthenia gravis. The nurse evaluates that the client understands the teaching about this drug when the client makes what statement regarding drug management plans? A. "Keep the drug in a container in the refrigerator." B. "Take the drug at the exact time that is listed on the prescription." C. "Plan to take the drug between meals to promote absorption." D. "Expect that the onset of the action of the drug will occur several hours after I take it."

B. "Take the drug at the exact time that is listed on the prescription." Rationale: Neostigmine should be taken as prescribed, usually before meals, to limit dysphagia and possible aspiration. Keeping neostigmine refrigerated is not necessary; it may be kept at room temperature. Neostigmine should be taken with milk to prevent gastrointestinal irritation; usually it is taken about 30 minutes before meals. The onset of the action of neostigmine occurs 45 to 75 minutes after administration; the duration of its action is 2.5 to 4 hours.

A client with myasthenia gravis has been receiving neostigmine and asks about its action. What information about its action should the nurse consider when formulating a response? A. Stimulates the cerebral cortex B. Blocks the action of cholinesterase C. Replaces deficient neurotransmitters D. Accelerates transmission along neural sheaths

B. Blocks the action of cholinesterase Rationale: Neostigmine, an anticholinesterase, inhibits the breakdown of acetylcholine, thus prolonging neurotransmission. Neostigmine's action is at the myoneural junction, not the cerebral cortex. Neostigmine prevents neurotransmitter breakdown, but it is not a neurotransmitter. Neostigmine's action is at the myoneural junction, not the sheath.

A client newly diagnosed with myasthenia gravis is to begin taking pyridostigmine, a cholinesterase inhibitor. Two days later the client develops loose stools and increased salivation. What conclusion does the nurse make about these new developments? A. Indicative of a myasthenic crisis B. Cholinergic effects C. A temporary response D. Toxic effects of the medication

B. Cholinergic effects Rationale: Because this drug inhibits the destruction of acetylcholine, parasympathetic activity may be increased. The signs do not indicate a myasthenic crisis. Myasthenic crisis is characterized by difficulty breathing or speaking, morning headaches, feeling tired during the daytime, waking up frequently at night, not sleeping well, weak cough with increased secretions (mucus or saliva), an inability to clear secretions, a weak tongue, trouble swallowing or chewing, and weight loss. Side effects are not temporary; they continue as long as the drug is continued. The dosage may be adjusted or an anticholinergic given to limit side effects. Toxicity or cholinergic crisis is manifested by increased muscle weakness, including muscles of respiration.

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? A. Problems with cognition B. Difficulty swallowing saliva C. Intention tremors of the hands D. Nonintention tremors of the extremities

B. Difficulty swallowing saliva Rationale: Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

What clinical finding does the nurse expect when assessing a client with myasthenia gravis? A. Partial improvement of muscle strength with mild exercise B. Fluctuating weakness of muscles innervated by the cranial nerves C. Dramatic worsening in muscle strength with anticholinesterase drugs D. Minimal changes in muscle strength regardless of the therapy initiated

B. Fluctuating weakness of muscles innervated by the cranial nerves Rationale: Myasthenia gravis is a chronic disorder of muscles enervated by weakened cranial nerves; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs increase, not decrease, muscle strength. Anticholinesterase drugs improve muscle strength.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? A. Encourage bed rest. B. Space activities throughout the day. C. Teach the limitations imposed by the disease. D. Have one of the client's relatives stay at the bedside.

B. Space activities throughout the day. Rationale: Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? A. Hiking B. Swimming C. Sewing Classes D. Watching television

B. Swimming Rationale: Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? A. "Tell me about your fears regarding pain." B. "Analgesics will be prescribed to control the pain." C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." D. "Let's make a list of the things you need to ask your healthcare provider."

C. "Some clients report feeling a tingling or burning sensation but not unbearable pain." Rationale: The response, "Some clients report feeling a tingling or burning sensation [1] [2], but not unbearable pain," is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it does not occur in all clients. These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations). The response, "Tell me about your fears regarding pain," avoids the client's question and may increase anxiety. Analgesics are not commonly prescribed unless pain results from some other condition. The response, "Let's make a list of the things you need to ask your healthcare provider," avoids the client's question and abdicates the nurse's responsibility.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? A. "Most individuals with your disease live a normal life span." B. "Is your family here? I would like to explain your disease to all of you." C. "The prognosis is variable; most individuals experience remissions and exacerbations." D. "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

C. "The prognosis is variable; most individuals experience remissions and exacerbations." Rationale: "The prognosis is variable; most individuals experience remissions and exacerbations" is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you" avoids the client's question; the family did not ask the question. The response "Why don't you speak with your healthcare provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? A. A genetic defect in the production of acetylcholine (ACh) B. An inefficient use of the neurotransmitter acetylcholine C. A decreased number of functioning acetylcholine receptor (AChR) sites D. An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

C. A decreased number of functioning acetylcholine receptor (AChR) sites Rationale: One of the pathologic changes is fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites. There is no genetic defect in the production of ACh; rather than a genetic cause, it is thought that myasthenia gravis has an autoimmune etiology. Although the defect is at the neuromuscular junction, it is not an inefficiency in the use of ACh but a decrease in the number of receptor sites for ACh. AChE is inhibited by anticholinesterase drugs used to treat myasthenia gravis, leaving more ACh available to the damaged or decreased ACh receptors.

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information? A. Plan activities for later in the day. B. Eat meals in a semirecumbent position. C. Avoid people with respiratory infections. D. Take muscle relaxants when under stress.

C. Avoid people with respiratory infections. Rationale: Respiratory infections place people with myasthenia gravis at high risk because they do not cough effectively and may develop pneumonia or airway obstruction. Activity should be conducted earlier in the day before the energy reserve is depleted; periods of activity should be alternated with periods of rest. The client should eat sitting in a chair to prevent aspiration. Taking muscle relaxants when under stress is contraindicated; these potentiate weakness because of their effect on the myoneural junction.

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? A. High cure rate with proper treatment B. Slowly progressive course without remissions C. Chronic illness with exacerbations and remissions D. Poor prognosis, with death occurring in a few months

C. Chronic illness with exacerbations and remissions Rationale: Myasthenia gravis is a chronic disorder with remissions and exacerbations that are precipitated by emotional stress, ingestion of alcohol, and physiologic stress such as infection. There is no cure for myasthenia gravis, but it can be managed. The disease is characterized by exacerbations and remissions. The disease is chronic. Death does not occur within a short period.

A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine is prescribed. When teaching the client about this medication, the nurse explains to expect an increase in what function? A. Intestinal peristalsis B. Salivary and gastric secretions C. Contraction of skeletal muscles D. Secretion and discharge of tears

C. Contraction of skeletal muscles Rationale: Anticholinesterase drugs inactivate cholinesterase, allowing sufficient acetylcholine to mediate stronger muscle responses. Increasing intestinal peristalsis is not a therapeutic response to pyridostigmine. Increasing salivary and gastric secretions are side effects of, not therapeutic responses to, pyridostigmine. Secretion and discharge of tears are side effects of, not therapeutic responses to, pyridostigmine.

A client with myasthenia gravis is to receive immunosuppressive therapy. What assures the nurse that this therapy will be effective? A. Inhibits the breakdown of acetylcholine at the neuromuscular junction B. timulates the production of acetylcholine at the neuromuscular junction C. Decreases the production of autoantibodies that attack acetylcholine receptors D. Promotes the removal of autoantibodies that impair the transmission of impulses

C. Decreases the production of autoantibodies that attack acetylcholine receptors Rationale: Steroids decrease the body's immune response, limiting the production of antibodies that attack acetylcholine receptors at the neuromuscular junction. Inhibiting the breakdown of acetylcholine at the neuromuscular junction is the action of anticholinergic medications. Stimulating the production of acetylcholine at the neuromuscular junction is not the action of immunosuppressives. Promoting the removal of autoantibodies that impair the transmission of impulses is the rationale for plasmapheresis.

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do? A. Plan a schedule of specific times each day that will be set aside for playtime with the children. B. While in remission, provide support to other people with multiple sclerosis who also have young children. C. Develop a flexible schedule for completion of routine daily activities. D. Meet with a self-help group for people with the diagnosis of multiple sclerosis.

C. Develop a flexible schedule for completion of routine daily activities. Rationale: The client must be flexible and adjust activities to provide for rest when necessary; activity should cease before the point of fatigue. Although quality time with children is important, it must be done on a flexible schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis who also have young children cannot be done if the client is in need of support or if it overtaxes physical resources. Meeting with a self-help group for people with the diagnosis of multiple sclerosis may not be a need at this time; prevention of fatigue always is important.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? A. Cogwheel gait B. Impaired cognition C. Difficulty swallowing D. Nonintention tremors

C. Difficulty swallowing Rationale: Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? A. Ability to chew and speak distinctly B. Capacity to smile and close the eyelids C. Effectiveness of respiratory exchange and ability to swallow D. Degree of anxiety and concern about the suspected diagnosis

C. Effectiveness of respiratory exchange and ability to swallow Rationale: Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.

During an exacerbation of multiple sclerosis a client reports urinary urgency and frequency. What is the most appropriate initial nursing action? A. Begin teaching self-catheterization. B. Develop a plan to ensure high fluid intake. C. Palpate the suprapubic area of the abdomen. D. Initiate a regimen to monitor urinary output.

C. Palpate the suprapubic area of the abdomen. Rationale: Assessment is the priority; the nurse should determine whether clinical manifestations are caused by a full bladder. Teaching self-catheterization may be necessary eventually, but it is not the initial action. Ensuring an increase in fluid intake may be done to reduce urinary bacterial count and stone formation, but it is not the initial action. Initiating a regimen to monitor urinary output should be done, but it is not the initial action.

A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? A. "You may be able to lessen your feelings of guilt by seeking counseling." B. "It would be helpful if you become involved in volunteer work at this time." C. "I recognize it's hard to deal with this, but try to remember that this too shall pass." D. "Joining a support group of people who are coping with this problem may be helpful."

D. "Joining a support group of people who are coping with this problem may be helpful." Rationale: Talking with others in similar circumstances provides support and allows for sharing of experiences. The response "You may be able to lessen your feelings of guilt by seeking counseling" is inappropriate because the feeling of guilt was not expressed directly and is too early for this intervention. The response "It would be helpful if you become involved in volunteer work at this time" avoids the partner's concerns and makes a recommendation for which the partner may not have the energy. Also, it cuts off communication. Although the response "I recognize it's hard to deal with this, but try to remember that this too shall pass" identifies feelings, it offers false reassurance.

A client with myasthenia gravis is receiving pyridostigmine bromide to control symptoms. Recently, the client has begun experiencing increased difficulty in swallowing. What nursing action is most effective in preventing aspiration of food? A. Place a tracheostomy set in the client's room. B. Assess respiratory status after meals. C. Request for the diet to be changed from soft to clear liquids. D. Coordinate mealtimes with the peak effect of the medication.

D. Coordinate mealtimes with the peak effect of the medication. Rationale: Dysphagia should be minimized during peak effect of pyridostigmine bromide, thereby decreasing the probability of aspiration. A tracheostomy set is a treatment for, rather than equipment to prevent, aspiration. Although it is vital that the client's respiratory function be monitored, assessing the client's respiratory status will not prevent aspiration. There are insufficient data to determine whether changing the diet from soft foods to clear liquids is appropriate; also, liquids are aspirated more easily than semisolids.

A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what? A. Electromyography B. Pyridostigmine test C. History of physical deterioration D. Edrophonium chloride test

D. Edrophonium chloride test Rationale: Edrophonium chloride test uses a drug that is a cholinergic and an anticholinesterase; it blocks the action of cholinesterase at the myoneural junction and inhibits the destruction of acetylcholine. Its action of increasing muscle strength is immediate for a short time. The results of an electromyography will be added to the database, but they are nonspecific. Pyridostigmine is a slower-acting anticholinesterase drug that is prescribed commonly to treat myasthenia gravis; edrophonium chloride is used instead of pyridostigmine to diagnose myasthenia gravis because, when injected intravenously, it immediately increases muscle strength for a short time. The results of a history and physical are added to the database, but the data collected are not as definitive as another specific test for the diagnosis of myasthenia gravis.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? A. Virus-induced iritis B. Intracranial pressure C. Closed-angle glaucoma D. Optic nerve inflammation

D. Optic nerve inflammation Rationale: Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Which assessment finding should the nurse expect the client to report? A. Weakness decreases after hot baths B. Weakness improves with muscle use C. Strength improves immediately after meals D. Strength decreases with repeated muscle use

D. Strength decreases with repeated muscle use Rationale: Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength as the day progresses. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement

Pyridostigmine is prescribed for a client with myasthenia gravis. Why does the nurse instruct the client to take pyridostigmine about one hour before meals? A. This timing limits the appetite. B. It promotes absorption. C. Taking it before meals prevents gastric irritation. D. Taking it before meals increases ability to chew.

D. Taking it before meals increases ability to chew. Rationale: Peak action of the medication will occur during meals to promote chewing and swallowing and prevent aspiration. It should be given with a small amount of food to prevent gastric irritation. Pyridostigmine improves muscle strength; it does not affect appetite. Absorption is not affected significantly by the presence of food in the stomach. Gastric irritation is reduced best by the administration of drugs with food, not on an empty stomach.

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? A. Recognize that depression often occurs after surgery B. Ask the primary healthcare provider to arrange for a psychologic consultation C. Reassure the client that things will feel better after the discharge date has been set D. Talk with the client about the prognosis and emphasize activities the client is still able to perform

D. Talk with the client about the prognosis and emphasize activities the client is still able to perform Rationale: Honest discussion with emphasis on functional and psychologic abilities helps promote adjustment. Postoperative depression is not a characteristic feature of thymectomy. Asking the client's practitioner to arrange for a psychologic consultation is too soon; it may eventually be necessary if the client has difficulty adjusting to the chronicity of this condition. Reassuring the client that things will feel better when the discharge date is set provides false reassurance; there is no guarantee the client will feel better on discharge.

A client with myasthenia gravis, who is living in a nursing home, experiences inadequate symptomatic control with pyridostigmine bromide, and long-term steroid therapy has been initiated. What is especially important for the nurse to ensure? A. The client increases sodium intake. B. Protective isolation is established. C. Total daily fluid intake is decreased. D. The client is monitored for an exacerbation of symptoms.

D. The client is monitored for an exacerbation of symptoms. Rationale: Exacerbation of myasthenia gravis may occur temporarily at the beginning of steroid therapy, causing respiratory embarrassment and dysphagia. Increasing sodium intake is contraindicated because steroids increase sodium retention. Although clients should avoid contact with persons who have upper respiratory infections, protective isolation (neutropenic precautions) is not required. Decreasing total daily fluid intake is unnecessary; adequate fluid intake should be maintained.

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report? A. The tremors increase when I fall asleep. B. The tremors increase when I feel fatigued. C. The tremors increase when I become nervous. D. The tremors increase when I perform an activity.

D. The tremors increase when I perform an activity. Rationale: Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.