med/surg chap 46 Myasthenia Gravis & Guillain Barre
The nurse teaches a client who has Guillain-Barré syndrome (GBS) about pain management. Which statement indicates that the client correctly understands the teaching?
"A combination of morphine and distraction helps bring me relief right now."
A client with trigeminal neuralgia is about to undergo surgery for pain relief. The client asks, "How will this surgery relieve my pain?" How does the nurse respond?
"A small artery compressing the nerve will be relocated."
The nurse is obtaining a health history for a 45-year-old woman with Guillain-Barré syndrome (GBS). Which statement by the client does the nurse correlate with the client's diagnosis?
"I had a viral infection about 2 weeks ago."
The nurse is teaching a client who is receiving carbamazepine (Tegretol) for chronic trigeminal neuralgia. Which statement indicates that the client correctly understands the teaching?
"I will avoid drinking alcohol because it can add to the side effects of this medicine."
The nurse teaches a client who has autonomic dysfunction about injury prevention. Which statement indicates that the client correctly understands the teaching?
"I will change positions slowly."
The nurse teaches a client with Guillain-Barré syndrome (GBS) about the recovery rate of this disorder. Which statement indicates that the client correctly understands the teaching?
"I will have to take things slowly for several months after I leave the hospital."
The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs. The client asks why the timing of meals is so important. Which is the nurse's best response?
"This timing allows the drug to have maximum effect, so it is easier for you to chew, swallow, and not choke."
The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities. Which instruction does the nurse include in the teaching plan?
"Use a thermometer to check the temperature of bath water."
The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis. Which complication does the nurse monitor for during this procedure?
Hypovolemia
The nurse is caring for a client who has undergone peripheral nerve repair. Which priority assessment does the nurse perform postoperatively?
Assess the skin surrounding the cast.
A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride) test. Which prescribed medication does the nurse prepare to administer if complications of this test occur?
Atropine sulfate
A client with myasthenia gravis is preparing for discharge. Which instructions does the nurse include when educating the client's family members or caregiver?
Cardiopulmonary resuscitation (CPR)
The nurse is caring for a client who has myasthenia gravis. Which nursing intervention does the nurse implement to reduce muscle weakness in this client?
Collaborate with the physical therapist.
The nurse is assessing a client with trigeminal neuralgia. Which clinical manifestation does the nurse expect to observe?
Controllable facial twitching
The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action?
Document the finding.
The nurse is assessing laboratory results for a client with myasthenia gravis (MG). Which results does the nurse correlate with this disease process?
Elevated acetylcholine receptor antibody levels
A client has just undergone surgery for peripheral nerve trauma. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)
Immobilization of the affected area with a splint Occupational therapy Skin care, including hygiene and ointments
The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?
Inability to perform the six cardinal positions of gaze
The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS). Which result does the nurse correlate with this disease process?
Increased cerebrospinal fluid (CSF) protein level
The nurse is preparing a staff in-service program related to restless legs syndrome (RLS). Which potential risk factors of this syndrome does the nurse include? (Select all that apply.)
Polyneuropathies Diabetes mellitus type 2
The intensive care nurse is caring for a client who has Guillain-Barré syndrome. The nurse notes that the client's vital capacity has declined to 12 mL/kg, and the client is having difficulty clearing secretions. Which is the nurse's priority action?
Prepare the client for elective intubation.
The nurse assesses a client who has Guillain-Barré syndrome. Which clinical manifestation does the nurse expect to find in this client?
Progressive, ascending weakness and paresthesia
A client who has myasthenia gravis is receiving atropine for a cholinergic crisis. Which intervention does the nurse implement for this client?
Suction the client to remove secretions.
A client who has myasthenia gravis is recovering after a thymectomy. Which complication does the nurse monitor for in this client?
Sudden onset of shortness of breath
The nurse is assessing a client who is experiencing a myasthenia crisis. Which diagnostic test does the nurse anticipate being ordered?
Tensilon test
The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?
The immune system destroys the myelin sheath.
A client who has Guillain-Barré syndrome is scheduled for plasmapheresis. Before the procedure, which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt?
The presence of a bruit
The nurse is preparing to send a cerebrospinal fluid sample to the laboratory. Which actions does the nurse implement during this procedure? (Select all that apply.)
Use Standard Precautions. Send the specimen in a sealed bag displaying a biohazard symbol. Confirm the specimen label with the client's identification band.