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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.
A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse would include which client problem in the plan of care?
A) Inability to care for self
B) Interruption in skin integrity
C) Interruption in physical mobility
D) Inability to perform daily activities
C) Interruption in physical mobility
Multiple sclerosis is a chronic, nonprogressive, noncontagious degenerative disease of the central nervous system characterized by demyelination of the neurons. Interruption in physical mobility is most appropriate for the client with multiple sclerosis experiencing muscle weakness, spasticity, and ataxic gait. The remaining options are not related to the data in the question.
The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention would be included in the care plan for this client? Select all that apply.
A) Provide oral hygiene after each meal.
B) Assess swallowing ability frequently.
C) Allow the client sufficient time to eat.
D) Maintain a suction machine at the bedside.
E) Provide a full liquid diet for ease in swallowing.
A) Provide oral hygiene after each meal.
B) Assess swallowing ability frequently.
C) Allow the client sufficient time to eat.
D) Maintain a suction machine at the bedside.
A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client needs to be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning needs to be available for clients who experience dysphagia and are at risk for aspiration.
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 is reviewing the record for a client seen in the health care clinic and notes that the primary health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder would the nurse expect to see documented in the record?
A) Muscle wasting
B) Mild clumsiness
C) Altered mentation
D) Diminished gag reflex
B) Mild clumsiness
The initial symptom of ALS is a mild clumsiness, usually noted in the distal portion of 1 extremity. The client may complain of tripping and drag 1 leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations.
A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?
A) A symmetrical smile
B) Difficulty closing the eyelid on the affected side
C) Narrowing of the palpebral fissure on the affected side
D) Paroxysms of excruciating pain in the lips and cheek on the affected side
B) Difficulty closing the eyelid on the affected side
The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia.
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.
A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness?
A) Giving client full control over care decisions and restricting visitors
B) Providing positive feedback and encouraging active range of motion
C) Providing information, giving positive feedback, and encouraging relaxation
D) Providing intravenously administered sedatives, reducing distractions, and limiting visitors
C) Providing information, giving positive feedback, and encouraging relaxation
The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
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.
The home care nurse is performing an assessment on a client with a diagnosis of Bell's palsy. Which assessment question will elicit specific information regarding this client's disorder?
A) "Do your eyes feel dry?"
B) "Do you have any spasms in your throat?"
C) "Are you having any difficulty chewing food?"
D) "Do you have any tingling sensations around your mouth?"
C) "Are you having any difficulty chewing food?"
Bell's palsy is a one-sided facial paralysis caused by compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and speech or chewing difficulties.
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
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 client with multiple sclerosis is receiving baclofen. The nurse assessing the client monitors for which finding as an indication of a primary therapeutic response to the medication?
A) Decreased nausea
B) Decreased muscle spasms
C) Increased muscle tone and strength
D) Increased range of motion of all extremities
B) Decreased muscle spasms
Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Increased muscle tone and strength and increased range of motion of all extremities are not directly related to the effects of this medication. Decreased nausea is an incorrect option.
The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen. Which information would the nurse include in the instructions?
A) Watch for urinary retention as a side effect.
B) Stop taking the medication if diarrhea occurs.
C) Restrict fluid intake while taking this medication.
D) Notify the primary health care provider if fatigue occurs.
A) Watch for urinary retention as a side effect.
Baclofen, a skeletal muscle relaxant, also is a central nervous system (CNS) depressant, which can cause urinary retention. The client would not restrict fluid intake. Constipation, rather than diarrhea, is an adverse effect of baclofen. Fatigue is a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary to notify the primary health care provider if fatigue occurs.
The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?
A) Drinking a total of 1000 mL/day
B) Giving self an enema every morning before breakfast
C) Taking stool softeners daily and a glycerin suppository once a week
D) Initiating a bowel movement every other day, 45 minutes after the largest meal of the day
D) Initiating a bowel movement every other day, 45 minutes after the largest meal of the day
To manage constipation, the client needs to take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client needs to initiate a bowel movement on an every-other-day basis and would sit on the toilet or commode. This would be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas would be avoided whenever possible because they lead to dependence.
A client is admitted with an exacerbation of multiple sclerosis. The nurse is assessing the client for possible precipitating risk factors. Which factor, if reported by the client, would the nurse identify as being unrelated to the exacerbation?
A) Annual influenza vaccination
B) Ingestion of increased fruits and vegetables
C) An established routine of walking 2 miles each evening
D) A recent period of extreme outside ambient temperatures
B) Ingestion of increased fruits and vegetables
The onset or exacerbation of multiple sclerosis can be preceded by a number of different factors, including physical stress (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruits and vegetables is a healthy and an unrelated item.
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.