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A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide
(Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this
client’s discharge teaching?
"Avoid crowds and people with colds.”
“Take you medication before bedtime.”
" Check blood sugar before bedtime to monitor for hypoglycemia.”
“Take prescribed medications when symptoms occur"
"Avoid crowds and people with colds.”
The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the client’s symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
“Take this drug on an empty stomach for best absorption.”
“Seek immediate care if you develop trouble swallowing.”
“Do not eat a full meal for 45 minutes after taking the drug.”
“Your urine may turn a reddish-orange color while on this drug.”
“The dose may change frequently depending on symptoms.”
“Seek immediate care if you develop trouble swallowing.”
“Do not eat a full meal for 45 minutes after taking the drug.”
“The dose may change frequently depending on symptoms.”
Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client’s manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The client’s urine will not turn reddish-orange while on this drug.
When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should:
inspect the skin for rashes or discoloration.
assess for the presence of chest pain.
inquire about urinary tract problems.
ask the patient about any increase in energy before bed.
inquire about urinary tract problems.
Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in energy is common with MS.
The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell’s palsy. Which information should the nurse include in teaching the patient?
a.
"You may be able to prevent Bell's palsy by doing facial exercises regularly."
b.
"Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."
c.
"Medications to treat Bell's palsy work only if started before paralysis onset."
d.
"Call the doctor if you experience pain or develop herpes lesions near the ear."
Call the doctor if you experience pain or develop herpes lesions near the ear
A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP). Which statements should the nurse include when delegating this client’s care? (Select all that apply.)
“Schedule additional time for teaching about prescribed therapies.”
“Plan to bathe the client in the evening when the client is most alert.”
“Remind the client to look at foot placement when walking.”
“Encourage the client to use a cane when ambulating.”
“Assess the client for symptoms related to pain and discomfort.”
“Plan to bathe the client in the evening when the client is most alert.”
“Remind the client to look at foot placement when walking.”
“Encourage the client to use a cane when ambulating.”
Which patient assessment will help the nurse identify potential complications of trigeminal neuralgia?
Inspect the oral mucosa and teeth.
Have the patient clench the jaws.
Identify trigger zones by lightly touching the affected side.
Assess lung sounds for possible aspiration.
Inspect the oral mucosa and teeth.
Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided. Aspiration is not a high priority risk factor for TN.
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.)
Ask occupational therapy to help the client with activities of daily living.
Provide the client with information on support groups.
Refer the client to a medical social worker or chaplain.
Consult with the provider about a physical therapy consult.
Ask occupational therapy to help the client with activities of daily living.
Refer the client to a medical social worker or chaplain.
Consult with the provider about a physical therapy consult.
A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find?
Hyperresponsive reflexes
Excessive somnolence
Heat intolerance
Nystagmus
Nystagmus
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
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
Obtaining atropine sulfate
Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.
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.)
Monitor calorie count when meal is complete
Cutting foods up into small bites
Screen patient for aspiration while feeding the patient
Thickening liquids prior to drinking
Cutting foods up into small bites
Thickening liquids prior to drinking
Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The nurse assesses the calorie count and swallow screen.
Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?
The patient complains of somnolence since starting this medication.
The patient reports no difference in symptoms after taking this medication for 10 days.
The patient has an increased serum creatinine level.
The patient walks a mile each day for exercise.
The patient has an increased serum creatinine level.
Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered. Therapeutic affect will be in 6 weeks.
A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client?
Jerky hand movements
Continuous chewing motions
Shuffling gait
Tremors of the hands
Jerky hand movements
An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs. Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson disease.
A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How should the nurse document this client’s assessment using the Glasgow Coma Scale shown below?
8
12
14
10
12
The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor response: Obeys commands = 6). Therefore, the client's Glasgow Coma Scale score is: 3 + 3 + 6 = 12.
Which medication taken by a patient with restless legs syndrome should the nurse discuss with
the patient?
Folic Acid
Asprin
Diphenhydramine
Vitamin B-12
Diphenhydramine
Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
Assess hematocrit and hemoglobin levels
Evaluate the client’s renal function.
Ensure that an informed consent is present.
Auscultate bilateral breath sounds
Ask the client about any allergies.
Evaluate the client’s renal function.
Ensure that an informed consent is present.
Ask the client about any allergies.
A client who is scheduled to receive iodine-based contrast should be asked about allergies, especially allergies to iodine or shellfish. The client’s kidney function should also be evaluated to determine if it is safe to administer contrast during the procedure. Finally, the nurse should ensure that an informed consent is present because all clients receiving iodine-based contrast must give consent. The CT will have no impact on the client’s breath sounds or hematocrit and hemoglobin levels. Findings from these assessments will not influence the client’s safety during the procedure.
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
Dysarthria
Muscle weakness
Dysphagia
Impairment of respiratory muscles
Impairment of respiratory muscles
In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS
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The nurse assessing a patient with newly diagnosed trigeminal neuralgia will ask the patient about
visual problems caused by ptosis.
weakness on the affected side of the face.
poor appetite caused by loss of taste.
triggers leading to facial discomfort.
triggers leading to facial discomfort.
The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
Use simple words and phrases to explain procedures.
Assist with active range of motion (ROM).
Observe for agitation and paranoia.
Assess for altered level of consciousness.
Assist with active range of motion (ROM).
ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient’s ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
Obtain a prescription for intravenous fluids.
Contact the provider to cancel the procedure.
Educate the client about strict bedrest after the procedure
Place an indwelling urinary catheter to closely monitor output.
Obtain a prescription for intravenous fluids.
If a contrast medium is used, intravenous fluid may be given to promote excretion of the contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid replacement. The client will not require bedrest. Although urinary output should be monitored closely, there is no need for an indwelling urinary catheter. There is no need to cancel the procedure as long as actions are taken to protect the kidneys.
A client is scheduled for CT scanning of the head because of a recent onset of neurologic deficits. What should the nurse tell the client in preparation for this test?
“You need to fast for 8 hours prior to the test.”
“There will be a lot of noise during the test.”
“No metal objects can enter the procedure room.”
“You will need to lie still throughout the procedure.”
“You will need to lie still throughout the procedure.”
Preparation for CT scanning includes teaching the client about the need to lie quietly throughout the procedure. If the client were having an MRI, metal and noise
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
The patient has taken topiramate (Topamax) for 2 months.
The patient had a recent myocardial infarction.
Family reports patient has been found often sitting alone in a dark room.
The patient recently joined the gym.
The patient had a recent myocardial infarction.
The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
“MS symptoms may worsen in the last trimester of pregnancy.”
“MS symptoms may be worse after the pregnancy.”
“Symptoms of MS are likely to become worse during pregnancy.”
“Women with MS are more likely to twins or triplets.”
“MS symptoms may be worse after the pregnancy.”
During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. Infants tend to be smaller than gestational age. Symptoms of MS may improve during pregnancy.
A client with Guillain--Barré syndrome has experienced a sharp decline in vital capacity. What is the nurse's most appropriate action?
Prepare to assist with intubation
Remind the client of the importance of deep breathing and coughing exercises
Administer bronchodilators as prescribed
Administer supplementary oxygen by nasal cannula
Prepare to assist with intubation
For the client with Guillain--Barré syndrome, mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate. Each of the other listed actions is likely insufficient to meet the client's oxygenation needs.
Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?
Respiratory effort
Level of consciousness
decreased ROM
Energy level
Respiratory effort
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
“Are you taking any cardiac medications?”
“Have you had a recent blood transfusion?”
“Do you have allergies to iodine or shellfish?”
“When was your last caffeine intake?”
“Do you have allergies to iodine or shellfish?”
Allergies to iodine and/or shellfish need to be explored because the client may have a similar reaction to the dye used in the procedure. In some cases, the client may need to be medicated with antihistamines or steroids before the test is given. A recent blood transfusion or current use of cardiac medications or oral contraceptives would not affect the angiography. Caffeine does not affect MRI testing.