Ch. 44 Flashcards
A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?
a.
Bladder control
b.
Cognitive perception
c.
Respiratory system
d.
Sensory functions
ANS: C
Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
DIF: Applying/Application REF: 915
The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what?
a.
Delayed afferent nerve impulses
b.
Paralysis of affected muscles
c.
Paresthesia in upper extremities
d.
Slowed nerve impulse transmission
ANS: D
Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
DIF: Remembering/Knowledge REF: 914
A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
a.
Anxiety
b.
Low fluid volume
c.
Inadequate airway
d.
Potential for skin breakdown
ANS: C
Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
DIF: Analyzing/Analysis REF: 914
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
ANS: C
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.
DIF: Applying/Application REF: 919
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
a.
Avoid large crowds and people who are ill.
b.
Check blood sugars four times a day.
c.
Use two forms of contraception.
d.
Wear properly fitting socks and shoes.
ANS: A
Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.
DIF: Applying/Application REF: 920
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met?
a.
Ability to chew and swallow without aspiration
b.
Eating 75% of meals and between-meal snacks
c.
Intake greater than output 3 days in a row
d.
Weight gain of 3 pounds in 1 month
ANS: D
Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the client’s meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
DIF: Evaluating/Synthesis REF: 921
A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
a.
“I can scratch with a coat hanger.”
b.
“I should feel my fingers for warmth.”
c.
“I will keep the cast clean and dry.”
d.
“I will return to have the cast removed.”
ANS: A
Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.
DIF: Evaluating/Synthesis REF: 925
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best?
a.
Advise the client to restrict fluids.
b.
Assess the client for signs of infection.
c.
Have the client add table salt to food.
d.
Instruct the client on a magnesium supplement.
ANS: D
Iron and magnesium deficiencies can sometimes exacerbate or increase symptoms of restless leg syndrome. The client’s magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed.
DIF: Applying/Application REF: 925
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
a.
“Avoid having teeth pulled for 1 year.”
b.
“Brush your teeth with a soft toothbrush.”
c.
“Do not use harsh chemicals on your face.”
d.
“Inform your dentist of this procedure.”
ANS: C
The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the face because he or she will not feel burning or stinging on that side. This will help avoid injury. The other instructions are not necessary.
DIF: Understanding/Comprehension REF: 927
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?
a.
Ask the client to explain his feelings related to this disorder.
b.
Explain how dental hygiene is related to overall health.
c.
Refer the client to a medical social worker for assessment.
d.
Tell the client that he will become malnourished in time.
ANS: A
Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
DIF: Applying/Application REF: 927
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
a.
Giving antibiotics prior to treatments
b.
Monitoring the client’s vital signs
c.
Performing appropriate hand hygiene
d.
Placing the client in protective isolation
ANS: C
Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
DIF: Applying/Application REF: 915
An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
a.
Assess the client’s oxygen saturation.
b.
Check the medication list for interactions.
c.
Place the client on a bed alarm.
d.
Put the client on safety precautions.
ANS: A
In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client’s oxygen saturation. The other actions are appropriate, but only after this assessment occurs.
DIF: Applying/Application REF: 916
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
a.
“MG is an autoimmune problem in which nerves do not cause muscles to contract.”
b.
“MG is an inherited destruction of peripheral nerve endings and junctions.”
c.
“MG consists of trauma-induced paralysis of specific cranial nerves.”
d.
“MG is a viral infection of the dorsal root of sensory nerve fibers.”
ANS: A
MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.
DIF: Understanding/Comprehension REF: 917
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
a.
“Do not eat a full meal for 45 minutes after taking the drug.”
b.
“Seek immediate care if you develop trouble swallowing.”
c.
“Take this drug on an empty stomach for best absorption.”
d.
“The dose may change frequently depending on symptoms.”
e.
“Your urine may turn a reddish-orange color while on this drug.”
ANS: A, B, D
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.
DIF: Understanding/Comprehension REF: 920
A client has been diagnosed with Bell’s palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.)
a.
Acyclovir (Zovirax)
b.
Carbamazepine (Tegretol)
c.
Famciclovir (Famvir)
d.
Prednisone (Deltasone)
e.
Valacyclovir (Valtrex)
ANS: A, C, D, E
Possible pharmacologic treatment for Bell’s palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell’s palsy.
DIF: Remembering/Knowledge REF: 927
