Question 1

A client who has myasthenia gravis is recovering after a thymectomy.Which complication does the nurse monitor for in this client?

Accepted Answer

The complication to be alert for is pneumothorax or hemothorax.The nurse monitors the client for chest pain,sudden onset of shortness of breath,diminished chest wall expansion,decreased breath sounds,restlessness,and changes in vital signs.The other symptoms are not likely to occur or are not related to removal of the thymus.

Question 2

The nurse is assessing a client who is experiencing a myasthenia crisis.Which diagnostic test does the nurse anticipate being ordered?

Accepted Answer

The Tensilon test in an important procedure for a client in myasthenic crisis.Cholinesterase-inhibiting drugs should be withheld because they increase respiratory secretions,which enhance the manifestations of a myasthenic crisis.A Babinski reflex and caloric reflex test would not be appropriate for this client.

Question 3

The intensive care nurse is caring for a client who has Guillain-Barré syndrome.The nurse notes that the client's vital capacity has declined to 12 mL/kg,and the client is having difficulty clearing secretions.Which is the nurse's priority action?

Accepted Answer

Deterioration in vital capacity to less than 15 mL/kg and an inability to clear secretions are indications for elective intubation.The other interventions may assist with breathing and oxygenation but would not reverse the deterioration in vital capacity or help clear secretions.

Question 4

A client who has myasthenia gravis is receiving atropine for a cholinergic crisis.Which intervention does the nurse implement for this client?

Accepted Answer

Atropine can cause thickening of secretions and formation of mucous plugs.The client is maintained on a ventilator during the crisis.Measures to remove secretions to prevent the buildup of secretions and the possibility of pneumonia are most important.The other interventions do not relate to the administration of atropine.

Question 5

A client who has Guillain-Barré syndrome is scheduled for plasmapheresis.Before the procedure,which clinical manifestation does the nurse use to determine patency of the client's arteriovenous shunt?

Accepted Answer

Nursing care of the client undergoing plasmapheresis includes care of the shunt.The nurse checks for bruits every 2 to 4 hours for patency.Pulse and extremity assessments do not provide information related to shunt patency.Pressure within the shunt is not tested before treatment to determine patency.

Question 6

The nurse assesses a client who has myasthenia gravis.Which clinical manifestation does the nurse expect to observe in this client?

Accepted Answer

The most common assessment finding in more than 90% of clients with myasthenia gravis is involvement of the extraocular muscles.The nurse observes for inability or difficulty with tests of extraocular function,such as the cardinal positions of gaze.Ptosis and incomplete eye closure also may be observed.Altered hearing and absent reflexes are not common in myasthenia gravis.

Question 7

The nurse instructs a client who has myasthenia gravis to take prescribed medications on time and to eat meals 45 to 60 minutes after taking anticholinesterase drugs.The client asks why the timing of meals is so important.Which is the nurse's best response?

Accepted Answer

Skeletal muscle weakness extends to the ability to chew and swallow.Clients who have myasthenia gravis are at risk for aspiration during meals.Timing the medication so that most of the meal is eaten when the drugs have produced their peak effect enables the client to chew and swallow more easily.The medication has no effect on blood glucose levels,ulcers,or nausea.

Question 8

The nurse recognizes which pathophysiologic feature as a hallmark of Guillain-Barré syndrome?

Accepted Answer

In Guillain-Barré syndrome,the immune system destroys the myelin sheath,causing segmental demyelination.Nerve impulses are transmitted more slowly but remain in place.Antibodies are not developed.The nerves do not degenerate and retract.

Question 9

A client with myasthenia gravis is preparing for discharge.Which instructions does the nurse include when educating the client's family members or caregiver?

Accepted Answer

Respiratory compromise is a common occurrence with myasthenia gravis.The client's family members are encouraged to learn CPR and to have resuscitation equipment available in the home.The other interventions are not a priority.

Question 10

The nurse is assessing laboratory results for a client with myasthenia gravis (MG).Which results does the nurse correlate with this disease process?

Accepted Answer

Testing for acetylcholine receptor (AChR)antibodies is important because 80% to 90% of clients with the disease have elevated AChR antibody levels.The other laboratory results are not associated with myasthenia gravis.

Question 11

The nurse assesses a client with Guillain-Barré syndrome during plasmapheresis.Which complication does the nurse monitor for during this procedure?

Accepted Answer

The client undergoing plasmapheresis is at risk for hypovolemia.The nurse monitors fluid status,assesses vital signs,and administers replacement fluid,as indicated.The other manifestations are not complications of plasmapheresis.

Question 12

The nurse teaches a client who has autonomic dysfunction about injury prevention.Which statement indicates that the client correctly understands the teaching?

Accepted Answer

Autonomic dysfunction causes orthostatic hypotension.The client should change positions slowly to prevent orthostatic hypotension.Autonomic dysfunction can cause peripheral polyneuropathy,so the client should be taught to wear socks and shoes at all times and not to use a heating pad.The disorder does not cause bleeding; therefore the client can use any type of razor.

Question 13

The nurse reviews laboratory data for a client who has Guillain-Barré syndrome (GBS).Which result does the nurse correlate with this disease process?

Accepted Answer

A lumbar puncture is performed to evaluate the CSF.An increased CSF protein level without increased cell count is a distinguishing feature of GBS.The other results are not associated with GBS.

Question 14

A client suspected to have myasthenia gravis is scheduled for the Tensilon (edrophonium chloride)test.Which prescribed medication does the nurse prepare to administer if complications of this test occur?

Accepted Answer

Tensilon increases cholinergic responses and can slow the heart rate down so that ectopic beats dominate,causing cardiac fibrillation or arrest.Atropine sulfate is an anticholinergic drug.The other medications are not appropriate for complications of this test.

Question 15

The nurse is planning discharge teaching for a client who has peripheral neuropathy of the lower extremities.Which instruction does the nurse include in the teaching plan?

Accepted Answer

The client with neuropathy has loss of sensation in the lower extremities,which can predispose the client to thermal injury.The client should be instructed to use a thermometer to check the temperature of the bath water to avoid a burn.Checking the water with the hands is not recommended because neuropathy may have a stocking and glove distribution that could also affect the hands.The client should be taught to wear shoes at all times,to assess feet and legs daily,to keep skin moist and clean,and not to cut calluses or corns from the feet.

Question 16

The nurse is assessing a client with trigeminal neuralgia.Which clinical manifestation does the nurse expect to observe?

Accepted Answer

Signs of trigeminal neuralgia are excruciating pain and uncontrollable facial twitching which causes the client to avoid talking,smiling,eating,or attending to hygienic needs.Sensory and mobility deficits are not associated with trigeminal neuralgia.

Question 17

The nurse is caring for a client who has undergone peripheral nerve repair.Which priority assessment does the nurse perform postoperatively?

Accepted Answer

The nurse assesses the skin surrounding the cast hourly for tightness,warmth,and color.If the cast is too tight,the nurse notifies the provider immediately.The other assessments should be completed after a circulatory assessment.

Question 18

The nurse is caring for a client who has myasthenia gravis.Which nursing intervention does the nurse implement to reduce muscle weakness in this client?

Accepted Answer

The hallmark of myasthenia gravis is muscle weakness that increases with fatigue.The nurse provides assistance with ADLs to prevent fatigue.The nurse collaborates with the physical therapist in teaching the client energy conservation techniques.Therapeutic massage,passive range of motion,and repositioning will not reduce muscle weakness.

Question 19

The nurse teaches a client with Guillain-Barré syndrome (GBS)about the recovery rate of this disorder.Which statement indicates that the client correctly understands the teaching?

Accepted Answer

Most clients make a full recovery from GBS.Recovery can take as long as 6 months to 2 years.Fatigue is a major lingering symptom for most of those diagnosed with this disorder.Clients are not permanently paralyzed.They are in an acute care environment during the acute phase of the disorder.

Question 20

The nurse assesses a client who has Guillain-Barré syndrome.Which clinical manifestation does the nurse expect to find in this client?

Accepted Answer

The most common clinical pattern of Guillain-Barré syndrome is the ascending variety.Weakness and paresthesia begin in the lower extremities and progress upward.The other manifestations are not associated with Guillain-Barré syndrome.

Quiz 46: Care of Patients With Problems of the Peripheral Nervous System