Week 4

Assessment

100

1) A nurse is assessing a client diagnosed with mutiple sclerosis. Which symptom would you expect to find? a.Vision changes b.Absent deep tendon reflexes c. Tremors at rest d. Flaccid muscles

Answer A. Rationale: Vision changes, such as diplopia. nystagmus, and blurred vision are symptoms of MS.

200

A client with weakness and tingling in both legs is admitted to the med-surg floor with a tentative diagnosis of Guillanarret syndrome. On admission, which assessment is most important for the client? a. Lung auscultation and measuremnets of vital capacity and tidal volume. b. Evaluation for signs and symtoms of increase itracranial pressure c. Evaluation of pain and discomfort d.Evaluation of nutritional status and metabolic state

Answer A. Rationale: Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure- the most serious complication of polyneuritis. In Guillan- Barret syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunkand involve the repiratory muscles.

300

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? a. decreased heart rate b. Increased restlessness c. Increased blood pressure d. Decreased level of Consciousness

Answer: B Rationale: In ALS an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress

400

When caring for a client with myasthenia gravis, the nurse should assess the client for which of the following manifestations of cholinergic crisis? Select all that apply. a. Ptosis b. Fasciculation c. Abdominal cramps d. Increased heart rate e. Decreased secretions and saliva f. Respiratory rate of 6 and irregular rhythm

Answers A, B, and F. Rationale: Cholinergic crisis is caused by overstimulation at the neuromuscular junction due to increased acetylcholine. The crisis affects the muscles that control eye and eyelid movement, causing fasciculation, ptosis (drooping eyelids) and difficulty chewing, talking, and swallowing. The muscles that control breathing and neck and limb movements are also affected, and respirations become slowed. Salivation is increased. The crisis is reversed with atropine.

500

The nurse should conduct a focused assessment with the client with multiple sclerosis for risk of which of the following? Select all that apply. a. Dehydration b. Falls c. Seizures d. Skin breakdown e. Fatigue

Answers B, D, and E. Rationale: The client with multiple sclerosis is at risk for falls due to muscle weakness, skin breakdown due to bowel and bladder incontinence, and fatigue. The client is not at risk for dehydration; seizures are not associated with myelin destruction.

Nursing Intervention

100

The nurse has given instructions to a client with Parkinson’s disease about maintaining mobility. Which action demonstrates that the client understands the directions? a. Sits in soft, deep chairs to promote comfort. b. Exercises in the evening to combat fatigue. c. Rocks back and forth to start movement with bradykinesia. d. Buys clothes with many buttons to maintain finger dexterity.

Answer C. Rationale: The client with Parkinson’s disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self.

200

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? a. Eating large, well-balanced meals b. Doing muscle-strengthening exercises. c. Doing all chores early in the day while less fatigued. d. Taking medications on time to maintain therapeutic blood levels.

Answer D. Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

300

When providing discharge teaching for a client with Multiple Sclerosis, the nurse should include which instructions? a. “Avoid Taking Daytime naps” b. “Avoid hot baths and showers” c. limit your fruit and vegetable intake d. restrict fluid intake to 1500ml/day

Answer B. Rationale: The nurse should instruct a client with MS to avoid hot baths and showers because they can exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.

400

A client with Guillain-Barre syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about paralysis, how should the nurse respond? a. The paralysis caused by the disease is temporary b. You will be permanently paralyzed, however you won’t have any sensory loss. c. It must be hard to accept the permanency of your paralysis. d. You’ll first regain use of your legs and then your arms

Answer A. Rationale: The nurse should inform the client that the paralysis that accompanies Guillain-Barre syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

500

A nurse is teaching a client with Multiple Sclerosis. When teaching the client how to reduce fatigue, the nurse should teach the client to: a. take a hot bath. b. rest in an air-conditioned room. c. increase the dose of muscle relaxants. d. Avoid naps during the day.

Answer B. Rationale: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue, however extreme cold should avoided. A hot bath shower will increase body temperature, producing fatigue.

Pharmacology

100

A nurse is administering neostigmine (Prostigmin) to a client with myasthenia gravis. Which nursing intervention should the nurse implement? a. Give the medication on an empty stomach b. warn the client that he'll experience mouth dryness c. give the medication before meals with a small amount of food d. Administer the medication for complaints of muscle weakness or difficulty swallowing

Answer C. Rationale: Neostigmine's onset of action is 45-75 min, it should be administered at least 45 min before eating to improve chewing and swallowing. Taking neostigmine with a small amount of food rather than on a completely empty stomach reduces GI adverse effects. Adverse effects of the medication include increased salivation, bradycardia, sweating, nausea, and abdominal cramps. Neostigmine must be given at scheduled times to ensure consistent blood levels.

200

A client with an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium) 25 mg PO daily which assessment finding indicates the medication is effective? a. Increased ability to sleep b. Relief from constipation c. Relief from pain d. Reduced muscle spasticity

Answer D. Rationale: Dantrolene reduces muscle spasticity, it doesn't increase the ability to sleep or relieve constipation or pain.

300

When teaching a client about carbidopa-levodopa (Sinemet) therapy for Parkinson's disease a nurse should include which instructions? a. Report any eye spasms b. Take this medication at bedtime c. Stop taking this drug when your symptoms disappear d. Be aware that your urine may appear darker than usual

Answer D. Rationale: Carbidopa-levodopa is used to replace insufficient dopamine in the client with Parkinson's disease, may cause harmless darkening of the urine. The drug doesn't cause eye spasms, although blurred vision is an expected adverse effect. The client should take levodopa-carbidopa shortly before meals, not at bedtime, and must continue to take it for life.

400

A health care provider has prescribed carbidopa-levodopa (Sinemet) four times per day for a client with Parkinson’s disease. The client wants “to end it all now that the Parkinson’s disease has progressed.” What should the nurse do? Select all that apply. a. Explain that the new prescription for Sinemet will treat the depression. b. Encourage the client to discuss feelings as the Sinemet is being administered. c. Contact the health care provider before administering the Sinemet. d. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. e. Determine if the client is at risk for suicide.

Answers C, D, and E. Rationale: The nurse should contact the health care provider before administering Sinemet because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with Sinemet can cause a hypertensive crisis. Sinemet is not a treatment for depression. Having the client discuss feelings is appropriate when the prescription is finalized.

500

A client with Parkinson’s disease is prescribed levodopa (L-dopa) therapy. Improvement in which of the following indicates effective therapy? a. Mood b. Muscle rigidity c. Appetite d. Alertness

Answers b Rationale: Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson’s disease.