Nokea
The nurse is preparing to provide care for a patient diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what?
- A. Genetic dysfunction
- B. Upper and lower motor neuron lesions
- C. Decreased conduction of impulses in an upper motor neuron lesion
- D. A lower motor neuron lesion
Correct Answer: D
Rationale: Myasthenia gravis results from a lower motor neuron lesion at the myoneural junction, causing muscle weakness. It is not genetic, nor does it involve upper motor neurons.
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A patient with MS has been admitted to the hospital following an acute exacerbation. When planning the patient's care, the nurse addresses the need to enhance the patient's bladder control. What aspect of nursing care is most likely to meet this goal?
- A. Establish a timed voiding schedule.
- B. Avoid foods that change the pH of urine.
- C. Perform intermittent catheterization q6h.
- D. Administer anticholinergic drugs as ordered.
Correct Answer: A
Rationale: A timed voiding schedule promotes bladder control in MS by training the bladder. Catheterization and anticholinergics are not first-line, and urine pH is irrelevant.
A patient with MS has developed dysphagia as a result of cranial nerve dysfunction. What nursing action should the nurse consequently perform?
- A. Arrange for the patient to receive a low residue diet.
- B. Position the patient upright during feeding.
- C. Suction the patient following each meal.
- D. Withhold liquids until the patient has finished eating.
Correct Answer: B
Rationale: Upright positioning during feeding reduces aspiration risk in MS-related dysphagia. Low-residue diets, routine suctioning, and withholding liquids are not indicated.
A 48-year-old patient has been diagnosed with trigeminal neuralgia following recent episodes of unilateral face pain. The nurse should recognize what implication of this diagnosis?
- A. The patient will likely require lifelong treatment with anticholinergic medications.
- B. The patient has a disproportionate risk of developing myasthenia gravis later in life.
- C. The patient needs to be assessed for MS.
- D. The disease is self-limiting and the patient will achieve pain relief over time.
Correct Answer: C
Rationale: Trigeminal neuralgia in patients under 50 may indicate MS, necessitating evaluation. It is not treated with anticholinergics, not linked to myasthenia gravis, and not self-limiting.
The nurse caring for a patient in ICU diagnosed with Guillain-Barr?© syndrome should prioritize monitoring for what potential complication?
- A. Impaired skin integrity
- B. Cognitive deficits
- C. Hemorrhage
- D. Autonomic dysfunction
Correct Answer: D
Rationale: Autonomic dysfunction, causing issues like heart rate variability, is a critical complication in Guillain-Barr?© syndrome. Skin integrity is a concern but less urgent, and cognitive deficits or hemorrhage are not typical.
A 33-year-old patient presents at the clinic with complaints of weakness, incoordination, dizziness, and loss of balance. The patient is hospitalized and diagnosed with MS. What sign or symptom, revealed during the initial assessment, is typical of MS?
- A. Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
- B. Flexor spasm, clonus, and negative Babinski's reflex
- C. Blurred vision, intention tremor, and urinary hesitancy
- D. Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Correct Answer: C
Rationale: Blurred vision (optic neuritis), intention tremor, and urinary hesitancy are typical MS symptoms due to demyelination. Deep tendon reflexes are hyperactive, Babinski's is positive, and abdominal reflexes are absent in MS.