Font size
WorksheetsSLE, MS, Guillain-Barres syndrome, Myasthenia Gravis
Total questions: 48
Worksheet time: 2hrs 35mins
The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is expected?
Complete metabolic panel and liver function tests
Complete blood count and antinuclear antibody tests
Cholesterol and lipid profile tests
Blood urea nitrogen and glomerular filtration tests
The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? SELECT ALL THAT APPLY
Use a sunscreen of SPF 30 or greater when in the sunlight
Notify the HCP immediately when developing a low-grade fever
Some dyspnea is expected and does not need immediate attention
The hands and feet may change color if exposed to cold or heat
Explain the client can be cured with continued therapy
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client?
The client will maintain reproductive ability
The client will verbalize feelings of body-image changes
The client will have no deterioration of organ function
The client's skin will remain intact and have no irritation
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?
Pericardial friction rub and crackles in the lungs
Muscle spasticity and bradykinesia
Hirsutism and clubbing of the fingers
Somnolence and weight gain
The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE?
The steroids will increase the body's ability to fight the infection
The steroids will decrease the chance of the SLE spreading to other organs
The steroids will suppress tissue inflammation, which reduces damage to organs
The steroids will prevent scarring of skin tissues associated with SLE
The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response?
"I know you are upset, but stress makes SLE worse."
"Please explain to me why you are crying?"
"I recommend going to an SLE support group."
"I see you are crying. We can talk if you would like."
The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented?
Use astringent lotion on the face and skin
Inspect the skin weekly for open areas or rashes
Dry the skin thoroughly by pating
Apply anti-itch medication between the toes
The nurse is caring for clients on a medical floor. Which client should be assessed first?
The client diagnosed with SLE who is complaining of chest pain
The client diagnosed with MS who is complaining of pain at a 10
The client diagnosed with myasthenia gravis who has dysphagia
The client diagnosed with GB syndrome who can barely move his toes
The nurse and a female UAP are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse?
The UAP washes her hands before and after performing vital signs on a client
The UAP dons sterile gloves prior to removing an indwelling catheter from a client
The UAP raises the head of the bed to high Fowler's position for a client about to eat
The UAP uses a fresh plastic bag to get ice for a client's water pitcher
The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response?
SLE occurs because the kidneys do not filter antibodies from the blood
SLE occurs after a viral illness as a result of damage to the endocrine system
There is no known identifiable reason for a client to develop SLE
This is an autoimmune disease that may have a genetic or hormonal component
The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing?
Tapering the medication prevents the client from having withdrawal symptoms
So the thyroid gland starts working, because this medication stops it from working
Tapering the dose allows the adrenal glands to begin to produce cortisol again
This is the health-care-provider's personal choice in prescribing the medication
The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)?
Nodules in the subcutaneous layer and deformity
Renal involvement and pleural effusions
Joint stiffness and pain
Raynaud's phenomenon and skin rash
The nurse is assessing a 48-year-old client diagnosed with multiple sclerosis. Which clinical manifestation warrants immediate intervention?
The client has scanning speech and diplopia
The client has dysarthria and scotomas
The client has muscle weakness and spasticity
The client has a congested cough and dysphagia
The client newly diagnosed with multiple sclerosis (MS) states, "I don't understand how I got multiple sclerosis. Is it genetic?" On which statement should the nurse base the response?
Genetics may play a role in susceptibility to MS, but the disease may be caused by a virus
There is no evidence suggesting there is any chromosomal involvement in developing MS
Multiple sclerosis is caused by a recessive gene, so both parents had to have the gene for the client to get MS
Multiple sclerosis is caused by an autosomal dominant gene on the Y chromosome, so only fathers can pass it on
The 30 year old female client is admitted with complaints of numbness, tingling, a crawling sensation affecting the extremities, and double vision which has occurred two times in the month. Which question is most important for the nurse to ask the client?
"Have you experienced any difficulty with your menstrual cycle?"
"Have you noticed a rash across the bridge of your nose?"
"Do you get tired easily and sometimes have trouble swallowing?"
"Are you taking birth control pills to prevent conception?"
The nurse enters the room of a client diagnosed with acute exacerbation of multiple sclerosis and finds the client crying. Which statement is the most therapeutic response for the nurse to make?
"Why are you crying? The medication will help the disease."
"You seem upset. I will sit down and we can talk for awhile."
"Multiple sclerosis is a disease that has god times and bad times."
"I will have the chaplain come and stay with you for a while."
The client diagnosed with multiple sclerosis is scheduled for a magnetic resonance imaging (MRI) scan of the head. Which information should the nurse teach the client about the test?
The client will have wires attached to the scalp and lights will flash on and off
The machine will be loud and the client must not move the head during the test
The client will drink a contrast medium 20 minutes to one hour before the test
The test will be repeated at intervals during a 5 to 6 hour period
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis "anticipatory grieving related to progressive loss." Which intervention should be implemented first?
Consult the physical therapist for assistive devices for mobility
Determine if the client has legal power of attorney
Ask if the client would like to talk to the hospital chaplain
Discuss the client's wishes regarding end-of-life care
The home health nurse is caring for the client newly diagnosed with multiple sclerosis. Which client issue is of most importance?
The client refuses to have a gastrostomy feeding
The client wants to discuss if she should tell her fiance
The client tells the nurse life is not worth living anymore
The client needs the flu and pneumonia vaccine
The nurse and a LPN are caring for a group of clients. Which nursing task should not be assigned to the LPN?
Administer a skeletal muscle relaxant to a client diagnosed with low back pain
Discuss bowel regimen medications with the HCP for the client on strict bedrest
Draw morning blood work on the client diagnosed with bacterial meningitis
Teach self-catherization to the client diagnosed with multiple sclerosis
The male client diagnosed with multiple sclerosis states he has been investigating alternative therapies to treat his disease. Which intervention is most appropriate by the nurse?
Encourage the therapy if it is not contraindicated by the medical regimen
Tell the client only the HCP should discuss this with him
Ask how his significant other feels about this deviation from the medical regimen
Suggest the client research an investigational therapy instead
The client diagnosed with an acute exacerbation of multiple sclerosis is placed on high-dose intravenous injections of corticosteroid medication. Which nursing intervention should be implemented?
Discuss discontinuing the proton pump inhibitor with the HCP
Hold the medication until after all cultures have been obtained
Monitor the client's serum blood glucose levels frequently
Provide supplemental dietary sodium with the client's meal
The nurse writes the client problem of "altered sexual functioning" for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
Encourage the couple to explore alternative ways of maintaining intimacy
Make an appointment with a psychotherapist to counsel the couple
Explain daily exercise will help increase libido and sexual arousal
Discuss the importance of keeping physically calm during sexual intercourse
The nurse is admitting a client diagnosed with multiple sclerosis. Which clinical manifestation should the nurse assess? SELECT ALL THAT APPLY
Muscle flaccidity
Lethargy
Dysmetria
Fatigue
Dysphagia
Which assessment data should the nurse assess in the client diagnosed with Guillain-Barre syndrome?
An exaggerated startle reflex and memory changes
Cogwheel rigidity and inability to initiate voluntary movement
Sudden severe unilateral facial pain and inability to chew
Progressive ascending paralysis of the lower extremities and numbness
Which statement by the client supports the diagnosis of Guillain-Barre syndrome?
"I just returned from a short trip to Japan."
"I had a really bad cold just a few weeks ago."
"I think one of the people I work with had this."
"I have been taking some herbs for more than a year."
Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barre syndrome?
Assess deep tendon reflexes
Complete a Glasgow Coma Scale
Check for Babinski's reflex
Take the client's vital signs
The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barre syndrome. Which preprocedure intervention has priority?
Keep the client NPO
Instruct the client to void
Place in the lithotomy position
Assess the client's pedal pulse
Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barre syndrome?
High risk for injury
Fear and anxiety
Altered nutrition
Ineffective breathing pattern
The nurse caring for the client diagnosed with Guillain-Barre syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem?
The client will have no skin irritation
The client will have no muscle atrophy
The client will perform range-of-motion exercises
The client will turn every two hours while awake
The client diagnosed with Guillain-Barre syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?
Provide an erase slate board for the client to write on
Instruct the client to blink once for "no" and twice for "yes"
Refer to a speech therapist to help with communication
Leave the call light within easy reach of the client
The client diagnosed with Guillain-Barre syndrome ask the nurse, "Will I ever get back to normal? I am so tired of being sick." Which statement is the best response by the nurse?
"You should make a full recovery within a few months to a year."
"Most clients with this syndrome have some type of residual disability."
"This is something you should discuss with the health-care team
"The rehabilitation is short and you should be fully recovered within a month."
The client admitted with rule-out Guillain-Barre syndrome has just had a lumbar puncture. Which intervention should the nurse implement postprocedure?
Monitor the client for hypotension
Apply pressure to the puncture site
Test the client's cerebrospinal fluid
Increase the client's fluid intake
The client diagnosed with Guillain-Barre syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?
The ventilator rate is set at 14 breaths per minute
A manual resuscitation bag is at the client's bedside
The client's pulse oximeter reading is 85%
The ABG results are pH 7.4, Pao1 88, Paco2 35, and Hco3 24
The client diagnosed with Guillain-Barres syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because the his wife is upset. Which action should the nurse implement?
Tell the wife she must stop crying
Escort the wife out of the room
Medicate the client immediately
Acknowledge the wife's fears
The client diagnosed with Guillain-Barre syndrome is admitted to the rehabilitation unit after 24 days in the acute care hospital. Which interventions should the nurse implement? SELECT ALL THAT APPLY
Refer the client to the physical therapist
Include the speech therapist in the team
Request a social worker consult
Implement a regimen to address pain control
Refer the client to the Guillain-Barre Syndrome Foundation
Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis?
Weakness and fatigue
Ptosis and diplopia
Breathlessness and dyspnea
Weight loss and dehydration
The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?
The client has no apparent change in assessment data
There is increased amplitude of electrical stimulation in the muscle
The circulating acetylcholine receptor antibodies are decreased
The client shows a marked improvement of muscle strength
Which surgical procedure should the nurse anticipate the client with myasthenia gravis undergoing to help prevent signs/symptoms of the disease process?
There is on surgical option
A transsphenoidal hypophysectomy
A thymectomy
An adrenalectomy
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
Discuss ways to help prevent chocking episodes
Explain how to care for a client on a ventilator
Teach how to perform passive range-of-motion exercises
Demonstrate how to care for the client's feeding tube
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
Occupational therapist
Recreational therapist
Vocational therapist
Speech therapist
The client with myasthenia gravis is undergoing plasmapheresis at the bedside. Which assessment date warrant immediate intervention?
The client's BP is 94/60 and AP is 112
Negative Chvostek's and Trousseu's signs
The serum potassium level is 3.5 mEq/L
Ecchymosis at the vascular site access
Which statement by the female client diagnosed with myasthenia gravis indicates the client needs more discharge teaching?
"I will not have any menstrual cycles because of this disease."
"I should avoid people who have respiratory infections."
"I should not take a hot bath or swim in cold water."
"I will drink at least 2500 mL of water a day."
The client diagnosed with myasthenia gravis is admitted to the emergency department with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing a cholinergic crisis?
The serum assay of circulating acetylcholine receptor antibodies is increased
The client's symptoms improve when administering a cholinesterase inhibitor
The client's blood pressure, pulse, and respirations improve after IV fluid
The Tensilon test does not show improvement in the client's muscle strength
The client diagnosed with myasthenia gravis is admitted with an acute exacerbation. Which interventions should the nurse implement? SELECT ALL THAT APPLY
Assist the client to turn and cough every 2 hours
Place the client in high Fowler's position
Assess the client's pulse oximeter reading every shift
Plan meals to promote medication effectiveness
Monitor the client's serum anticholinesterase levels
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
Discuss the Myasthenia Foundation with the client's wife
Refer the client to a local myasthenia gravis support group
Ask the client's wife if she would like to talk to a counselor
Sit down and allow the wife to ventilate her feelings to the nurse
The client with myasthenia gravis is prescribed the cholinesterase inhibitor neostigmine (Prostigmin). Which data indicate the medication is effective?
The client is able to feed self independently
The client is able to blink the eyes without tearing
The client denies any nausea or vomiting when eating
The client denies any pain when performing ROM exercises
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
Administer the medication 30 minutes prior to meals
Instruct the client to take 8 ounces of water
Explain the importance of sitting up one hour after taking medication
Assess the client's blood pressure prior to administrating medication
