N102 Neurological EAQ
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? 1 Weakness decreases after hot baths 2 Weakness improves with muscle use 3 Strength improves immediately after meals 4 Strength decreases with repeated muscle use
4 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.
Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? 1 A raised toilet seat 2 Side rails for the bed 3 A trapeze above the bed 4 Crutches for ambulation
1 A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.
A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? 1 Muscle weakness improving after a period of rest 2 Symptoms worse in the morning upon awakening 3 Periods of hyperactivity 4 Slow, insidious onset of muscle weakness
1 Increased activity and stress precipitate exacerbation of symptoms because nerve impulses fail to pass to muscles at the myoneural junction with myasthenia gravis; theories include inadequate acetylcholine, excessive cholinesterase, or a nonresponse of the muscle fibers to acetylcholine. Symptoms improve after rest or a good night's sleep. Hyperactivity is not associated with myasthenia gravis. Muscle weakness and fatigue come on quickly and disappear rapidly with rest in the initial stages of myasthenia gravis. Rest promotes a decrease in symptoms associated with myasthenia gravis because the demand for muscle contraction is reduced.
A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention? 1 Space activities throughout the day. 2 Restrict activities and encourage bed rest. 3 Teach the client about limitations imposed by the disorder. 4 Have a family member stay at the bedside to give the client support.
1 Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychologic adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not address the concerns voiced by the client.
When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? 1 Avoid leaning forward. 2 Hesitate between steps. 3 Rest when tremors are experienced. 4 Keep arms close to the center of gravity.
1 The client with Parkinson disease often has a stooped posture [1] [2] [3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.
A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the last several months?"
1. "Have you experienced an infection recently?" Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Drug therapy is not implicated as a contributing factor in Guillain-Barré syndrome.
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? 1 Problems with cognition 2 Difficulty swallowing saliva 3 Intention tremors of the hands 4 Nonintention tremors of the extremities
2 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.
The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? 1 Take a hot bath. 2 Rest in an air-conditioned room. 3 Increase the dose of muscle relaxants. 4 Avoid naps during the day.
2 Fatigue is a common symptom in clients with multiple sclerosis . Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue.
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? 1 "You don't feel able to make a decision at this time?" 2 "Have you spoken to your fiancé about your feelings?" 3 "Your fiancé loves you and I'm sure still wants to marry you." 4 "These are your feelings now, but don't decide until you feel better and can cope."
1. "You don't feel able to make a decision at this time?" 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 is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply. 1 Muscle rigidity 2 Blank facial expression 3 Leaning toward the affected side 4 Intention tremors with movement 5 Hyperextension of the affected extremity
1, 2 With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (CVA). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.
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. 1 Double vision 2 Problems with cognition 3 Difficulty swallowing saliva 4 Intention tremors of the hands 5 Drooping of the upper eyelids 6 Nonintention tremors of the extremities
1, 3, 5 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.
Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply. 1 Double vision 2 Resting tremors 3 Flaccid paralysis 4 Scanning speech 5 Mental retardation
1, 4 Diplopia (double vision) and nystagmus (involuntary, rapid, rhythmic eye movements) are experienced by clients with multiple sclerosis as a result of demyelination. Scanning (clipped) speech occurs with multiple sclerosis as a result of demyelination. These clients exhibit the Charcot triad: intention tremor, nystagmus, and scanning speech. Clients experience intention, not resting, tremors. Clients experience spastic paralysis because upper motoneurons are involved. Although emotional affect and speech are affected, intelligence remains intact.
A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression
1. Physical Therapy Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome
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. 1 Using Credé maneuver 2 Using an indwelling catheter 3 Using anticholinergic medications 4 Monitoring and restricting fluid intake to 800 mL daily 5 Monitoring for and reporting signs of urinary tract infection
1, 5 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.
A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. 1 Resting tremors 2 Flattened affect 3 Muscle flaccidity 4 Tonic-clonic seizures 5 Slow voluntary movements
1,2,5 Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.
A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. 1 Nonintention tremors 2 Frequent bouts of diarrhea 3 Masklike facial expression 4 Hyperextension of the neck 5 Rigidity to passive movement
1,3,5 Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.
A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 Headaches 2 Nystagmus 3 Skin infections 4 Scanning speech 5 Intention tremors
1,4,5 Involuntary, rhythmic movements of the eyes (nystagmus) and other visual disturbances, such as diplopia and blurred vision, are common initial symptoms of optic nerve lesions. Some common initial signs of multiple sclerosis are scanning speech, intention tremors, and nystagmus. These adaptations are associated with disseminated demyelination of nerve fibers of the brain and spinal cord. Although this is a neuromuscular disorder, headaches are not a common symptom. Pressure ulcers may occur late, not early, in the progression of the illness because of immobility, and these pressure ulcers may become infected.
A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion? 1 Difficulty breathing 2 Decline in physical mobility 3 Disturbed sensory perception 4 Decreased tolerance to activity
1. Excessive weakness and impaired diaphragmatic innervation result in an ineffective ability to breathe; difficulty breathing, ineffective airway clearance, and ineffective gas exchange support the conclusion that the client is in myasthenic crisis. A decline in physical mobility is not as definitive as respiratory difficulty. A disturbance in sensory perception is not as definitive as respiratory distress; blurred vision and pupillary miosis occur with cholinergic crisis. Deterioration in activity tolerance is not as definitive as respiratory distress; this is a common occurrence in clients with myasthenia gravis.
A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations? 1 Blurred vision along with episodes of vertigo 2 Tremors of the hands when attempting to lift objects 3 Partial improvement of muscle strength with mild exercise 4 Involvement of the distal muscles rather than the proximal muscles
1. Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.
A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? 1 Aspiration 2 Dehydration 3 Nutritional imbalance 4 Impaired communication
1. 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.
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? 1 Encourage the client to rest for short periods. 2 Continue the bath while supporting the client's arms. 3 Gradually increase the client's activity level each day. 4 Administer a dose of pyridostigmine bromide.
1. 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.
A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little or no change of muscle strength regardless of therapy initiated 4 Dramatic worsening of muscle strength with anticholinesterase drugs
2 Muscle use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected [1] [2]. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs improve muscle strength. Anticholinesterase drugs increase, not decrease, muscle strength.
A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? 1 Administer oxygen 2 Raise the head of the bed 3 Perform tracheal suctioning 4 Call the healthcare provide
2 Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Oxygen will not assist in the management of dysphagia [1] [2] or the prevention of aspiration. Performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the healthcare provider to the problem is necessary, but only after client safety is ensured.
A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care? 1 Maintaining bed rest 2 Providing frequent rest periods 3 Reassuring the client that there are many tasks that still can be performed 4 Arranging for a relative to be present
2 Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion and should be avoided. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the client is observed closely by the nursing staff; however, it should be permitted if requested by the client or family.
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? 1 Encourage bed rest. 2 Space activities throughout the day. 3 Teach the limitations imposed by the disease. 4 Have one of the client's relatives stay at the bedside
2 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.
The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? 1 Decreased physical mobility related to stooped posture 2 Risk for injury related to gait disturbances 3 Impaired skin related to drooling 4 Pain related to headache
2 The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.
A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred? 1 Suddenly 2 Gradually 3 Overnight 4 Irregularly
2 The onset of this disease is not sudden, but insidious, with a prolonged course and gradual progression. The onset is slow and gradual. The onset is not irregular; there is a gradual, regular progression of symptoms.
When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little change regardless of the therapy initiated 4 Dramatic worsening with anticholinesterase drugs
2 Use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected, and therefore muscle weakness will fluctuate in relation to activity and rest. Muscle strength decreases, not increases, with activity. Anticholinesterase drugs improve muscle strength.
A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait? 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric
2 With a shuffling gait [1] [2] [3] the steps are short and dragging; this is seen with basal ganglia defects. Ataxia is a staggering gait often associated with cerebellar damage. Scissoring is associated with bilateral spastic paresis of the legs. An asymmetric gait is associated with weakness of or pain in one lower extremity.
A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client? 1 Tearing 2 Diplopia 3 Nystagmus 4 Exophthalmos
2 With myasthenia gravis, the sensitivity of the end plates at the postsynaptic junction to acetylcholine is reduced, thus interfering with muscle contraction. Inadequate contraction of the ocular muscles results in double vision (diplopia). Tearing is not a clinical manifestation associated with myasthenia gravis. Nystagmus is not a clinical manifestation associated with myasthenia gravis; it is associated with multiple sclerosis. Exophthalmos is associated with hyperthyroidism.
. 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? 1 "I avoid use of a straw to drink liquids." 2 "I will take a hot bath to help relax my muscles." 3 "I plan to use an incontinence pad when I go out." 4 "I may be having a rough time now, but I hope tomorrow will be better."
2 "I will take a hot bath to help relax my muscles." 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
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? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television
2. 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.
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning
2. Increased muscular weakness Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.
What nursing intervention is anticipated for a client with Guillain-Barré syndrome? 1 Providing a straw to stimulate the facial muscles 2 Maintaining ventilator settings to support respiration 3 Encouraging aerobic exercises to avoid muscle atrophy 4 Administering antibiotic medication to prevent pneumonia
2. Maintaining ventilator settings to support respiration Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.
A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option? 1 Hemodialysis 2 Plasmapheresis 3 Thrombolytic therapy 4 Immunosuppression therapy
2. Plasmapheresis A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.
A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? 1 Auscultate for breath sounds. 2 Suction the client's oropharynx. 3 Administer and continue to monitor oxygen via nasal cannula. 4 Place the client in the orthopneic position.
2. Suction the client's oropharynx A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway. Oxygen administration will be useless if the airway is not patent. Placing the client in the orthopneic position is unsafe for a client with Guillain-Barré syndrome. The client will be unable to maintain this position. Muscle weakness involves the lower extremities, progressing to the upper extremities and diaphragm.
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? 1 Plan a schedule of specific times each day that will be set aside for playtime with the children. 2 While in remission, provide support to other people with multiple sclerosis who also have young children. 3 Develop a flexible schedule for completion of routine daily activities. 4 Meet with a self-help group for people with the diagnosis of multiple sclerosis.
3 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.
The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises? 1 Diarrhea 2 Salivation 3 Difficulty breathing 4 Abdominal cramping
3 Because of the decrease in tone and strength of the respiratory muscles, difficulty breathing is a prominent feature of both crises. Diarrhea occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Salivation occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Abdominal cramping occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis.
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? 1 Cogwheel gait 2 Impaired cognition 3 Difficulty swallowing 4 Nonintention tremors
3 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 has experienced an episode of myasthenic crisis. Upon review of the client history by the nurse, which finding will most likely be a precipitating factor of the myasthenic crisis? 1 Getting too little exercise 2 Taking excess medication 3 Omitting doses of medication 4 Increasing intake of fatty foods
3 Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine and pyridostigmine. Too little exercise is not a factor. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Fatty food intake is incorrect.
A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? 1 Ability to chew and speak distinctly 2 Capacity to smile and close the eyelids 3 Effectiveness of respiratory exchange and ability to swallow 4 Degree of anxiety and concern about the suspected diagnosis
3 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 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? 1 Plan activities for later in the day. 2 Eat meals in a semirecumbent position. 3 Avoid people with respiratory infections. 4 Take muscle relaxants when under stress.
3 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 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? 1 Brief exaggeration of symptoms 2 Prolonged symptomatic improvement 3 Rapid but brief symptomatic improvement 4 Symptomatic improvement of only the ptosis
3 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 client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first? 1 "Tell me more about your fears regarding pain." 2 "Medications will be prescribed to help control pain." 3 "Pain is a common symptom of this condition." 4 "Let's list your questions for the healthcare provider."
3 The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.
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? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Some clients report feeling a tingling or burning sensation but not unbearable pain." 4 "Let's make a list of the things you need to ask your healthcare provider."
3 The response, "Some clients report feeling a tingling or burning sensation , 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 healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase? 1 "The client will adhere to the teaching plan." 2 "The client will achieve psychologic adjustment." 3 "The client will maintain present muscle strength." 4 "The client will prepare for a possible myasthenic crisis."
3 Until the diagnosis has been confirmed, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis has not yet been established. The response "achieve psychologic adjustment" is too early; the client cannot adjust if a diagnosis has not yet been confirmed. The response "prepare for a possible myasthenic crisis" is an intervention, not an objective.
A primary healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing goal for the client during the diagnostic phase? 1 Adhere to a teaching plan. 2 Achieve psychologic adjustment. 3 Maintain present muscle strength. 4 Prepare for the development of myasthenic crisis.
3 Until the diagnosis is confirmed, the primary goal should be to maintain adequate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis is not yet established. It is too early to achieve psychologic adjustment; the client cannot adjust if a diagnosis is not yet confirmed. Preparing for the development of myasthenic crisis is not a goal.
To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1 Narrowed airways 2 Impaired immunity 3 Ineffective coughing 4 Viscosity of secretions
3 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 is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply. 1 Akinesia 2 Masklike face 3 Postural instability 4 Unilateral limb involvement 5 Increased gait disturbances
3, 5 Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurologic disorders of older adults. Stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. Akinesia is manifested in stage 4 of the disease. Clinical manifestation of stage 2 is "masklike" face. Unilateral limb involvement is seen in stage 1 of Parkinson disease.
A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange
4. Respiratory exchange The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.
A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? 1 Progressive deterioration until death 2 Deficiencies of essential neurotransmitters 3 Increased risk for respiratory complications 4 Involuntary twitching of small muscle groups
3. All three share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.
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? 1 High cure rate with proper treatment 2 Slowly progressive course without remissions 3 Chronic illness with exacerbations and remissions 4 Poor prognosis, with death occurring in a few months
3. 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 with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? 1 A genetic defect in the production of acetylcholine (ACh) 2 An inefficient use of the neurotransmitter acetylcholine 3 A decreased number of functioning acetylcholine receptor (AChR) sites 4 An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded
3. 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.
A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when documenting on the client's progress report? 1 Spastic 2 Steppage 3 Shuffling 4 Scissoring
3. Steps are short and dragging (shuffling); this is seen with defects of the basal ganglia. Spastic gait, short steps with dragging of foot, is associated with neurogenic causes like cerebral palsy. Steppage gait is when foot slaps down and is associated with peroneal nerve injury or paralyzed dorsiflexor muscles. Scissoring gait is associated with bilateral spastic paresis of the legs as occurs in cerebral palsy or hemiplegia.
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? 1 "Most individuals with your disease live a normal life span." 2 "Is your family here? I would like to explain your disease to all of you." 3 "The prognosis is variable; most individuals experience remissions and exacerbations." 4 "Why don't you speak with your healthcare provider? You probably can get more details about your disease."
3. "The prognosis is variable; most individuals experience remissions and exacerbations." "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.
Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs
3. Monitoring respiratory status The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning, or if the client is intubated, verbal communication abilities are lost.
Arrange the order of tests chronologically to be performed to determine the neurologic status of a client. 1. Speak in loud voice 2. Apply painful stimuli 3. Speak in normal voice 4. Shake the client gently
3. Speak in a normal voice 1. Speak in a loud voice 4. Shake client gently 2. Apply painful stimuli The assessment of neurologic status should start with speaking to the client in a normal voice. If the client does not respond, the nurse should speak loudly. If the client does not respond to this, the nurse should gently shake the client. The degree of shaking should be similar to that used in waking a child. If the client does not respond to this, painful stimuli can be applied.
A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed, and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? 1 Eat foods that are pureed. 2 Perform range-of-motion exercises. 3 Take a stool softener daily. 4 Take the medication according to a specific schedule.
4 A priority of care for a client with myasthenia gravis [1] [2] is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing. Dysphagia usually is not an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dysphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, range-of-motion exercises prevent joint contractures rather than promote muscle strength. Anticholinergic medications taken for myasthenia gravis cause relaxation of smooth muscle, resulting in diarrhea rather than constipation.
A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia? 1 Intention tremor 2 Muscle flaccidity 3 Paralysis of the limbs 4 Lack of spontaneous movement
4 Bradykinesia is a slowing down in the initiation and execution of movement. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.
A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? 1 Offer three large meals a day. 2 Assess the client's respiratory status before and after meals. 3 Seek a change in the diet prescription from soft foods to clear liquids. 4 Schedule meals with the peak effect of an anticholinesterase muscle stimulant.
4 Dysphagia should be minimized during the peak effect of an anticholinesterase muscle stimulant such as pyridostigmine, thereby decreasing the probability of aspiration. Three large meals a day will tire the client with myasthenia gravis. Assessing the client's respiratory status before and after meals will not prevent aspiration, although it is vital that respiratory function be monitored. Data are insufficient to determine whether changing the diet to clear liquids is appropriate because liquids also may be aspirated; liquids are more difficult to manage than are foods with the consistency of pudding.
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? 1 Recognize that depression often occurs after surgery 2 Ask the primary healthcare provider to arrange for a psychologic consultation 3 Reassure the client that things will feel better after the discharge date has been set 4 Talk with the client about the prognosis and emphasize activities the client is still able to perform
4 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 nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement? 1 "I'll take an antihistamine at the first sign of a cold." 2 "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." 3 "We've told our daughter to wait to visit until her cold is better." 4 "The healthcare provider may need to adjust the dosage of my medication if I'm more active."
4 Increased activity without an increase in medication can precipitate a myasthenic crisis [1] [2]. Self-medication may result in drug interactions; a change in medical therapy can have serious consequences. A dose should not be skipped because doing so may result in severe respiratory distress. People with myasthenia gravis should avoid crowds and others with colds; they are more prone to respiratory infections because of an ineffective cough and a potential for aspiration.
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? 1 The tremors increase when I fall asleep. 2 The tremors increase when I feel fatigued. 3 The tremors increase when I become nervous. 4 The tremors increase when I perform an activity.
4 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.
A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary healthcare provider only if other neurologic deficits are present. 2 Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. 3 Stress the importance of having the client call the primary healthcare provider as soon as possible. 4 Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.
4 Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.
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? 1 Virus-induced iritis 2 Intracranial pressure 3 Closed-angle glaucoma 4 Optic nerve inflammation
4 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 is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? 1 Disintegration of the myelin sheath 2 Breakdown of upper and lower neurons 3 Reduced acetylcholine receptors at synapses 4 Degeneration of the neurons of the basal ganglia
4 Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.
A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? 1 Gait training in the physical therapy department daily 2 Isometric exercises every two hours while awake 3 Active range-of-motion exercises at least every four hours 4 Passive range-of-motion exercises at least every eight hours
4 Passive range-of-motion exercises at least every eight hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every four hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.
. 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? 1 "You may be able to lessen your feelings of guilt by seeking counseling." 2 "It would be helpful if you become involved in volunteer work at this time." 3 "I recognize it's hard to deal with this, but try to remember that this too shall pass." 4 "Joining a support group of people who are coping with this problem may be helpful."
4. "Joining a support group of people who are coping with this problem may be helpful." 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 Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? 1 Localized seizures 2 Skin desquamation 3 Hyperactive reflexes 4 Ascending weakness
4. Ascending weakness The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Localized seizures are not a characteristic of Guillain-Barré syndrome. Skin desquamation is not a characteristic of Guillain-Barré syndrome. Deep tendon reflexes are absent with Guillain-Barré syndrome.