Iggy Chapter 44

1. 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. Respiratory System

MULTIPLE RESPONSE 1. 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."

a. "Do not eat a full meal for 45 minutes after taking the drug." b. "Seek immediate care if you develop trouble swallowing." d. "The dose may change frequently depending on symptoms."

3. 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. Inadequate airway

7. 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. "I can scratch with a coat hanger."

13. 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 problem in which nerves do not cause muscles to

2. 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)

a. Acyclovir (Zovirax) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)

5. 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.

a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. e. Work with speech therapy to design a high-protein diet.

10. 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. Ask the client to explain his feelings related to this disorder.

12. 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. Assess the client's oxygen saturation.

5. 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. Avoid large crowds and people who are ill. b. Check blood sugars four times a day.

4. 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

b. Advising the client to have help getting up c. Consulting the provider about the drug e. Placing the client on safety precautions

3. 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

b. Cutting foods up into small bites d. Thickening liquids prior to drinking

9. 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. "Do not use harsh chemicals on your face."

4. 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. Obtaining atropine sulfate

11. 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. Performing appropriate hand hygiene

8. 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. Instruct the client on a magnesium supplement.

2. 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. Slowed nerve impulse transmission

6. 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 of 3 pounds in 1 month