Myasthenia Gravis (MG)
Myasthenia gravis is an autoimmune disease of the neuromuscular junction characterized by fluctuating weakness of certain ___________ muscle groups.
Skeletal muscle
•Antibodies attack acetylcholine (Ach) receptors which results in decreased ACh sites at the NM junction, thus it prevents muscle contraction.
Multiple sclerosis is characterized by disseminated ________________ of nerve fibers of the brain and spinal cord. The pathophysiological changes results in _____________ formation.
Demyelination; plaque
The nurse admits a patient with advanced Parkinson’s disease at the outpatient clinic with a cough and fever. During assessment of the patient, the nurse would expect to find
1. slurred speech, visual disturbances, and ataxia.
2. muscle atrophy, spasticity, and speech difficulties.
3. muscle weakness, double vision, and reports of fatigue.
4. drooling, stooped posture, tremors, and a propulsive gait.
drooling, stooped posture, tremors, and a propulsive gait.
The ascending paralysis associated with Guillain-Barre’ can cause _____________ ___________ , which occurs as the paralysis progresses to the nerves that innervate the thoracic area.
Respiratory failure
•Constant monitoring of the respiratory system by checking the rate, depth, forced vital capacity, and negative inspiratory force provides information about he need for immediate intervention including intubation and mechanical intubation.
A patient is admitted to the ICU with a C7 spinal cord injury and diagnosed with Brown-Sequard syndrome. On physical examination, the nurse would most likely find
1. upper extremity weakness only.
2. complete motor and sensory loss below C7.
3. loss of position sense and vibration in both lower extremities.
4. ipislateral motor loss and contralateral sensory loss below C7.
ipislateral motor loss and contralateral sensory loss below C7
The nurse is providing care for a client experiencing a myasthenic crisis. What would be most important for the nurse to monitor?
1.Ability to swallow
2.Development of UTI
3.Pulse rate and rhythm
4.Daily weights and UOP
Ability to swallow
•During myasthenic crisis, the respiratory muscles are affected and aspiration is a concern. The crisis compromises respirations and may result in infections, aspiration, and respiratory insufficiency. Mechanical ventilation may be required. The immune, cardiovascular, hepatic, and renal systems may be involved, but these are not the priority systems in jeopardy.
When assessing a client with MS, the nurse would anticipate that the client initially experienced which symptom?
1.Fast, repetitive speech
2.Visual disturbances
3.Flaccid paralysis
4.Signs of inflammation
Visual disturbances
•The early signs of MS are often visual disturbances, including diplopia. The speech is slurred, not fast. There is patchy demyelination throughout the CNS, but not inflammation. Flaccid paralysis is not an early sign.
What percentage of dopamine-producing neurons in the substantia nigra of the midbrain is lost by the time that poor motor coordination occurs?
1.40%
2.60%
3.80%
4.100%
80%
The nurse is assisting a client with GB syndrome to set long term goals. He is currently in the recovery phase is experiencing paralysis from the waist down. Which long-term goal is realistic for this client?
1.Maintaining independence in a wheelchair with upper body conditioning.
2.Returning to normal function with no residual paralysis.
3.Maintaining independence in activities of daily living with minimal assistance.
4.Driving a car using hand-mounted controls.
Returning to normal function with no residual paralysis.
•With GB, the paralysis typically recedes down the body just as it ascended the body. Most clients will return to normal function with no residual paralysis. The client should not need any assistance with ADLs or mobility.
A 70-year-old patient has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient’s injury is most likely to be life threatening after completing rehabilitation?
1.Increased bone density loss
2.Higher risk for tissue hypoxia
3.Vasomotor compensation loss
4.Weakness of thoracic muscles
Weakness of thoracic muscles
• Weakness of thoracic muscles is most likely to cause life-threatening complications because it affects patient oxygenation and ventilation.
The nurse is assessing a newly diagnosed client with MG. Which assessment finding would the nurse classify as characteristic of the condition?
1.Tremor
2.Neuromuscular rigidity
3.Ptosis
4.Paresthesias of the lower extremities
Ptosis
•The primary problem of MG is skeletal muscle fatigue with sustained contraction; symptoms are predominately bilateral. Other signs include muscular ptosis (drooping eyelids) and diplopia (double vision). Fatigue increases with activity. Sensory deficits are not related to this condition. Tremor and rigidity are often seen in PD.
What would be appropriate to include in the treatment plan for health promotion in a client with a diagnosis of MS?
1.Avoiding aerobic exercise because of muscle weakness
2.Keeping warm (esp. extremities) to improve neurological function
3.Avoiding antioxidants (C, E, beta-carotene), because they contribute to loss of myelin sheath.
4.Consuming a low-fat, high-fiber diet, with increased fluids and vitamins
Consuming a low-fat, high-fiber diet, with increased fluids and vitamins
•Prevention of constipation and urinary problems is important. Keeping cool, not warm, is associated with improved neurologic function. A regular exercise program is encouraged, along with daily intake of a multivitamin, antioxidants, and low-dose aspirin. Maintaining ideal body weight, having rest periods, and being informed are also important.
An appropriate nursing diagnosis for a patient with advanced Parkinson’s disease is
1. risk for injury related to limited vision.
2. risk for aspiration related to impaired swallowing.
3. urge incontinence related to effects of drug therapy.
4. ineffective breathing pattern related to diaphragm fatigue.
Risk for aspiration related to impaired swallowing.
•As swallowing becomes more difficult (dysphagia), malnutrition or aspiration may result.
The nurse is caring for a patient who was admitted to the unit with suspected GB. A lumbar puncture is performed. The nurse explains the purpose of this procedure is to:
1.Determine the causative agent
2.Identify the presence of blood
3.Reduce the intracranial pressure
4.Measure the spinal fluid protein level
Measure the spinal fluid protein level
•No specific tests for GBS are available, so diagnosis is made by exclusion. A nerve conduction velocity test may show demyelination. An EMG, which records muscle activity, may show the speed at which signals travel along the nerves and the loss of reflexes caused by the slowing of nerve responses. The health care provider may also perform a lumbar puncture to analyze cerebrospinal fluid (CSF). In about 90% of GBS patients, CSF protein is elevated due to the release of plasma proteins from the inflammation, degeneration, and damage to nerve roots.
A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for
1. return of reflexes.
2. bradycardia with hypoxemia.
3. effects of sensory deprivation.
4. fluctuations in body temperature.
bradycardia with hypoxemia.
• Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. These effects are generally associated with a cervical or high thoracic injury (T6 or higher).
A 20-year old client with MG will undergo plasmaphoresis. Which actions describes the purpose of this procedure?
1.Preventing exacerbations during pregnancy
2.Removing T cells and B lymphocytes that attack acetylcholine receptors
3.Delivering acetylcholinesterase inhibitor directly into the bloodstream
4.Separating and removing acetylcholine receptor antibodies from the blood
Separating and removing acetylcholine receptor antibodies from the blood
•This is for clients refractory to the usual therapies or those in crisis. Although stress, including pregnancy, may precipitate a crisis, this is not the purpose.
A 30 year old female patient with MS has a nursing diagnosis of Impaired urinary elimination pattern r/t sensorimotor deficits and inadequate fluid intake AEB post-urination residual volume >50mL, dribbling, bladder distention.
Verbalize 2 appropriate interventions and the rationales.
•Administer cholinergic drugs as ordered to improve the muscle tone of bladder and facilitate bladder emptying.
•Follow intermittent catheterization protocol to prevent distention or dribbling.
•Use Crede’ maneuver or reflex stimulation as an alternative method of emptying bladder.
•Maintain fluid intake of 3000mL per day to dilute urine and reduce risk for UTI.
•Teach patient signs and symptoms of UTI to ensure early identification and treatment.
•Initiate bladder training program to help restore adequate bladder function.
A nurse determines a patient with Parkinson’s disease has Imbalanced nutrition: less than body requirements r/t dysphagia AEB difficulty swallowing and chewing, drooling, decreased gag reflex.
Verbalize 2 appropriate nursing interventions with rationales
•Carefully monitor swallowing ability during drug administration and mealtime to evaluate patient’s level of impairment and minimize risk of aspiration.
•Provide soft-solid and thick-liquid diet because these consistencies are more easily swallowed.
•Maintain patient in upright position for all meals to reduce risk of aspiration.
•Consult speech therapist and dietitian because they can provide specific plans to improve swallowing and intake.
•Have suction available to remove pooled secretions and prevent choking and aspiration.
The nurse is caring for a young man with GB. His mother asks if he will need “that breathing machine” for a long time. The correct response would be:
1.“Yes, your son is paralyzed and will never breathe on his own.”
2.“No, we should have him stabilized in the next 24-48 hours; he will be able to breath on his own.”
3.“Your son may need this breathing machine for a few days to a few months. As the paralysis recedes, he will gradually improve.”
4.“Yes, our social worker will be up to discuss advance directives with you.”
“Your son may need this breathing machine for a few days to a few months. As the paralysis recedes, he will gradually improve.”
During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which of the following findings would concern the nurse the most?
1. A heart rate of 92
2. A reddened area over the patient’s coccyx
3. Marked perspiration on the patient’s face and arms
4. A light inspiratory wheeze on auscultation of the lungs
Marked perspiration on the patient’s face and arms
• Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death.
One hour after receiving pyridostigmine bromide (Mestinon), a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the physician and prepares to administer which of the following medications?
1.Additional Mestinon
2.Atropine
3.Edrophonium (Tensilon)
4.Neostigmine (Prostigmin)
Atropine
•These symptoms suggest cholinergic crisis or excessive acetylcholinesterase medication, typically appearing 46-60 minutes after the last dose. Atropine, an anticholinergic drug, is used to antagonize the Ach inhibitors. The other drugs are Ach inhibitors- Tensilon for diagnosis and Mestinon & Prostigmin for treatment- which would worsen symptoms.
Interferon β-1b (Betaseron) has been prescribed for a young woman who has been diagnosed with relapsing-remitting multiple sclerosis. The nurse determines that additional teaching about the drug is needed when the patient says,
1. “I will need to rotate injection sites with each dose I inject.”
2. “I should report any depression or suicidal thoughts that develop.”
3. “I should avoid direct sunlight and use sunscreen and protective clothing when out of doors.”
4. “Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema.”
“Because this drug is a corticosteroid, I should reduce my sodium intake to prevent edema.”
•Rationale: Interferon β-1b (Betaseron) is an immunomodulator drug (and not a corticosteroid). The drug is given subcutaneously every other day. Patient teaching should include rotate injection sites with each dose; assess for depression, suicidal ideation; wear sunscreen and protective clothing while exposed to sun; know that flu-like symptoms are common following initiation of therapy.
A client with PD has been experiencing anorexia and vomiting since he began receiving levodopa. What will be the initial nursing activity?
1.Assess his food preferences
2.Monitor his blood pressure
3.Hold his medication and notify the physician
4.Administer the medication with food.
Administer the medication with food.
•The first side effect to be noticed may be GI problems. Taking it with meals may alleviate these symptoms. The client can continue taking it, and attempts should be made to minimize the side effects. Food preferences and BP are not relevant.
Which duty would be most appropriate to assign to the certified nursing assistant?
1.Assist in bathing a client with Guillain-Barre’ syndrome who is on the ventilator
2.Assist in bathing a client with pneumonia who is acutely short of breath
3.Assist in ambulating a client with a hemothorax and chest tube to water seal
4.Assist in feeding a client with a stroke and swallowing difficulties.
Assist in ambulating a client with a hemothorax and chest tube to water seal
•The lowest priority client in this situation is the one with the hemothorax and a chest tube, which does not require that the client be connected to suction. All of the other clients have conditions that require the assessment and attention of the RN.
A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to
1. breathe with respiratory support.
2. drive a vehicle with hand controls.
3. ambulate with long-leg braces and crutches.
4. use a powered device to handle eating utensils.
drive a vehicle with hand controls.
• A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: Ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0-6 hr/day.