Myasthenia Gravis NCLEX

The client diagnosed with MG is being discharged home. Which intervention should the nurse teach the significant other? 1. Discuss how to perform the Heimlich maneuver. 2. Explain how to perform oral hygiene on a conscious client. 3. Teach how to perform isometric exercises. l 4. Demonstrate correct hand placement for chest compressions.

Correct answer 1: The client is at risk for choking, and knowing specific measures to help the client helps decrease the client's as well as significant other's anxiety and promotes confidence in managing potential complications. The client should perform oral care. The client should perform isotonic exercises, not isometric exercises, and the client is not at an increased risk for cardiac complications, so teaching about chest compression is not necessary.

The client diagnosed with MG is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a myasthenic crisis? 1. The serum assay of circulating acetylcholine receptor antibodies is increased. 2. The client's symptoms improve when administering on a cholinesterase inhibitor. 3. The client's blood pressure, pulse, and respirations improve after intravenous (IV) fluid. 4. The Tensilon test does not show improvement in the client's muscle strength.

Correct answer 2: This assessment datum indicates a myasthenic crisis that is due to undermedication, missed doses of medication, or developing an infection. Serum assays are useful in diagnosing the disease, not in identifying a crisis. Vital signs do not differentiate the type of crisis. No improvement after Tensilon indicates a cholinergic crisis, not a myasthenic crisis.

The male client diagnosed with MG is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is not effective? l 1. The client is able to perform activities of daily living (ADLs) independently. l 2. The client states that his vision is clear. l 3. The client cannot speak or look upward at the ceiling. l 4. The client is smiling and laughing with the nurse.

Correct answer 3: Dysphonia and inability to utilize the muscles of the eye and eyelid indicate the medication is not effective. Performing ADLs, having clear vision, and smiling and laughing using the facial muscles indicate the medication is effective

The nurse is discharging a client diagnosed with MG. Which statement by the client indicates an understanding of the discharge instructions? 1. "I can control the MG with medication, but an adenectomy will cure it." 2. "I should take a holiday from my medications every 4 or 5 weeks." 3. "I must take my medications on time every day, or I could have problems." 4. "I should take my steroid medications with food so it won't upset my stomach."

Correct answer 3: The anti cholinesterase medications used to treat MG must be taken on time in order to prevent muscle weakness and respiratory complications. These medications are one of the very few that the nurse should administer at the exact scheduled time. Steroids are not prescribed for MG.

Which response to the Tensilon (edrophonium chloride) injection indicates the client has myasthenia gravis? 1. The client has no apparent change in the assessment data. 2. There is reduced amplitude of electrical stimulation in the muscle. 3. The anti-acetylcholine receptor antibodies are present. 4. The client shows a marked improvement of muscle strength.

Correct answer 4: Clients with myasthenia gravis show a significant improvement of muscle strength that lasts approximately 5 minutes when Tensilon (edrophonium chloride) is injected.

Which referral is appropriate for the client in the late stages of myasthenia gravis? 1. The infection control nurse. 2. The occupational health nurse. 3. A vocational guidance counselor. 4. The speech therapist.

Correct answer 4: Speech therapists address swallowing problems, and clients with myasthenia gravis are dysphagic and at risk for aspiration. The infection control and occupational health nurses do not consult with the client. A vocational counselor helps with the client finding a position suited for the disability, but clients with late-stage myasthenia gravis are usually not able to work.

The wife of a client diagnosed with MG is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse? A) Discuss the Myasthenia foundation w/ client's wife B) Refer client to a local MG support group C) Ask the pts. Wife if she would like to talk to a counselor D) Sit down & allow the wife to ventilate her feelings to the nurse

D

Your patient diagnosed with Myasthenia Gravis begins taking Mestinon. During the first week, the dosage is changed frequently. While the dosage is being adjusted, the nurse's priority intervention is to: A) Administer the medication with food or an 8 oz. glass of water B) Evaluate the client's muscle strength hourly after medication C) Take a full set of vital signs every 15 minutes D) Administer the medication exactly on time

D) Peak response occurs 1 hour after administration and lasts up to 8 hours. By giving the medication exactly on time, this will help determine dosage levels. Mestinon can be given with or without food/water. There is nothing in this question that indicates vitals should be taken every 15 minutes. The client's muscle strength is important to assess, but the priority intervention is to give the medication on time.

Which of the following would be most likely given as a top nursing diagnosis for a patient experiencing a cholinergic crisis? A) Impaired Gas Exchange B) Acute Fatigue C) Ineffective airway clearance D) Altered mental status

Answer: C. During a cholinergic crisis, secretions are increased and the gag reflex is decreased, putting the patient at risk for a blocked airway. Impaired gas exchange, while has to do with respiratory, is not as appropriate as ineffective airway clearance based on the problems of the crisis. Acute fatigue and altered mental status are not priorities.

The client diagnosed w/ myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others? A) discuss ways to help prevent choking episodes B) Explain how to care for a client on a ventilator C) Teach how to perform passive ROM exercises D) Demonstrate how to care for the client's feeding tube

A

The client w/ MG is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the med is effective? A) Client is able to feed self independently B) The client is able to blink the eyes w/out tearing C) The client denies and nasue/ vomit when eating D_ The client denies any pain when performing ROM

A

The client diagnosed w/ MG is admitted w/ an acute exacerbation. Which interventions should the nurse implement? SELECT ALL APPLY. A) Assist the pt. to turn and cough every 2 hrs B) Place client in high/ semi fowlers C) assess client's pulse ox reading every shift D) Plan meals to promote medication effectiveness E) Monitor client's serum anticholinesterase levels

A,B,D

The client is experiencing a myasthenic crisis. Which of the following is a priority action of the following ordered actions? A) Insert NG tube B) Administer Ativan C) Monitor I&O D) Immediately stop anticholinesterase medications

Answer: A. Inserting the NG tube is the priority because it will help reduce risk for aspiration. The patient experiencing a myasthenic crisis is at a large risk for respiratory failure due to dysphagia and extreme muscle weakness. All priority actions should be focused on respiratory assessment and support. Ativan and any other sedating medication should NEVER be administered. Stopping anticholinesterase medications is associated with a cholinergic crisis. Monitoring I&O is important, but not as important as NG tube

You are teaching your patient diagnosed with myasthenia gravis about treatments. Which of the following statements, if made by the patient indicates the need for further teaching? A) Plasmapheresis is way to reduce symptoms but will need to be done every day B) A thymectomy is a removal of my thymus gland and will show some immediate relieving of my symptoms C) Corticosteroids can be used for short periods of time to help improve my symptoms, but it isn't good for long periods of time D) I need to take my Mestinon four times a day at the same time each day.

Answer: B. A thymectomy may help reduce symptoms, but the effects may not be seen for many months after surgery. Plasmapheresis is the removal of antibodies from blood plasma. It must be done daily for a period of time. Corticosteroids are mostly used for short periods of time unless the patient is experiencing ocular complications. Pyridostigmine bromide (Mestinon) is divided into several doses and should be taken at the same time daily.

The patient with myasthenia gravis is complaining about dealing with muscle weakness. Which of the following could the nurse do for this patient? A) Administer antispasmodic medication B) Teach the patient to do physical exercise for several hours each day to help strengthen muscles C) Teach the patient it is important to avoid all forms of physical activity whenever possible D) Help the patient form a plan to take medications on time

Answer: D. Taking medications at the same time each day will help reduce the exacerbation of muscle weakness. Antispasmodic medications are not indicated for this patient. Exercising for that much time each day will worsen muscle weakness and fatigue and is not feasible. The patient does not need to avoid all forms of physical activity. They need to time out physical activity with peaks of the medication in order to conserve energy.

FLASH CARDS OF MG from here and down Which statement by the client supports the diagnosis of myasthenia gravis (MG)? 1. "I have weakness and fatigue in my feet and legs." 2. "My eyelids droop, and I see double everything." 3. "I get chest pain and faint after I walk in the hall." 4. "I gained 3 pounds this week, and I am spitting up pink frothy sputum."

Correct answer 2: These are ocular signs/symptoms of MG. Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral double vision. Weakness and fatigue of upper body muscle occur with MG. Option 3 is angina. Option 4 is heart failure.

The client w/ MG is admitted to the emergency room with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing cholinergic crisis? A) The serum assay of circulation ACH receptor antibodies is increased B) The client's symptoms improve when administering cholinesterase inhibitor C) Clients BP, pulse, and RR improve after IV fluid D) The tensilon test does not show improvement in the client's muscle strength

D

The patient with myasthenia gravis arrives to the clinic and states that he is experiencing nausea and diarrhea. His blood pressure is 125/85 HR 70 Temp 100.0 R 19 O2 97%. What is the nursing priority? A) Prepare the patient for intubation. He is about to go into a myasthenic crisis. B) Perform teaching on medication side effects C) Assess for signs of infection D) Further assess for other thymectomy complications

Answer: C. Although the GI symptoms is a common side effect of medicaitons, it is important to follow up on the high temperature and assess for sings of infection. An infection can often exacerbate a Myasthenic crisis and should be carefully monitored for. There is no evidence that this person is about to have a myasthenic crisis and intubation should only be done if the patient is experiencing respiratory failure. There is no evidence that this patient has had a thymectomy.

Which of the following is a side effect of Methylprednisolone (Solu-Medrol)? A) Hypovolemia B) Tinnitus C) Euphoria D) Respiratory Depression

Answer: C. Corticosteroid side effects include increased risk for infection, delayed wound healing, infection masking, edema, euphoria, insomnia, hypokalemia, hypocalcemia, hyperglycemia, osteoporosis, and peptic ulcer

Which surgical procdure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent the s/s of the disease process? A) There is no surgical option B) A transsphenoidal hypophysectomy C) A thymectomy D) An adrenalectomy

C

Which collab health care team member should the nurse refer the client to in the late stages of MG? A) Occupational therapist B) recreational Therapist C) Vocational therapist D) Speech Therapist

D

Which statement by the female client diagnosed w/ MG indicates the client needs more discharge teaching? A) I will not have a menstrual cycle bcs. Of the disease B) I should avoid people who have respiratory infections C) I should not take a hot back or swim in cold water D) I will drink at least 2,500 ml of h20 a day

A

The client w/ MG is undergoing plasmapheresis at the bedside. Which assessment data warrant immediate intervention? A) Client's BP is 94/60 and AP is 112 B) Negative Chvosteks & Trousseaus C) Serum potassium 3.5 D) Echymosis at vascular site access

A

The nurse is teaching a client about myasthenia gravis. Which statement, if made by the patient indicates the need for further teaching? A) The doctor will take me off of my beta blocker because it could exacerbate my symptoms B) I should report any signs of infection to my PCP C) I can take a ibuprofen to help with pain that may occur with spasms D) I should avoid taking long walks

Answer: C. OTC medication should be avoided as they may worsen MG symptoms. The doctor may stop a beta blocker as they can exacerbate symptoms (unless benefit outweighs the risk). Any signs of infection should be reported as they can exacerbate a myasthenic crisis. Long walks should be avoided due to muscle weakness and fatigue

Your patient has just been diagnosed with myasthenia gravis. Which of the following orders should be questioned? A) Prednisone PO daily B) Eyepatch to be worn every night C) Pyrodostigmine bromide (Mestinon) 4 times daily PO D) Procaine (Novocain) SQ stat to reduce pain in lower limb

Answer: D. Novocain is contraindicated in patients with MG because of its long lasting effects.

Which ocular or facial signs/ symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis? A) Weakness & Fatigue B) Ptosis & diplopia C) Breathlessness & dyspnea D) Weight loss & Dehydration

B

The client is diagnosed with MG. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)? 1. Assess for excess salivation and abdominal cramps. 2. Administer the medication before the client has eaten. 3. Break the capsule and sprinkle the medication on the food. 4. Assess the client's potassium level prior to administering medication.

Correct answer 1: Anticholinesterase medications can cause the client to have excessive salivation and abdominal cramping. When this occurs, the client receives the antidote atropine simultaneously in small doses. Mestinon is administered with milk and/or crackers to prevent stomach upset. Mestinon does not affect potassium levels.

The male client with MG is undergoing plasmapheresis at the bedside. Which assessment data would warrant immediate intervention by the nurse? 1. The client complains of being lightheaded and dizzy. 2. The client can smile and clamp his teeth together. 3. The client states that his leg cramps have gone away. 4. The client has a small hematoma at the vascular access site.

Correct answer 1: Hypovolemia is a complication of plasmapheresis, especially during the procedure when up to 15% of the blood volume is in the cell separator. The nurse should immediately assess for shock. All other options are expected.

Which statement by the 20-year-old female client diagnosed with MG indicates the client understands the discharge teaching? 1. "I can have children, but I will have to see my neurologist during my pregnancy." 2. "I have a new job at a children's day care center to help with expenses." 3. "I should not take a bath because I could pass out and drown while in the tub." 4. "I will drink at least 1000 mL of water or other liquid every day."

Correct answer 1: MG will not prevent conception or delivery but can cause the client to experience an exacerbation of the disease. The client should be seen regularly by the neurologist and the obstetrician. Young children are ill frequently, and infections can result in an exacerbation for the client. Option 3 applies to clients who have seizures. The client is not restricted to 1000 mL of fluid per day.

The client is being evaluated to rule out myasthenia gravis & being administered the Tensilon test. Which response to the test indicates the client has MG? A) The client has no apparent change in the assessment data B) This is increased amplitude of electrical stimulation in the muscle C) The circulating acetylcholine receptor antibodies are decreased D) The client shows a marked improvement of muscle strength

D