Chapter 23 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 23

Question 1

Type: MCMA

In order to care for adults with Alzheimers disease (AD), the nurse recognizes which common signs?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Poor or impaired judgment

2. Declining job skills

3. Inability to be comfortable in social situations

4. Obsession with organization

5. Focus on abstract thoughts

Correct Answer: 1,2,3

Rationale 1: Poor or impaired judgment is a warning sign of AD. This change may make the patient uncomfortable in social situations.

Rationale 2: Memory loss that negatively affects job skills is a warning sign of AD. This change may make the patient uncomfortable in social situations.

Rationale 3: The cognitive changes typical of AD may make the patient uncomfortable in social situations.

Rationale 4: Obsession with organization is not usually associated with Alzheimers.

Rationale 5: A focus on abstract thoughts is not usually associated with Alzheimers.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 2

Type: MCSA

Which medication would the nurse anticipate administering as treatment for mild Alzheimers disease (AD)?

1. Donepezil (Aricept)

2. Adrenocorticotropic hormone (ACTH)

3. Olanzapine (Zyprexa)

4. Memantine (Namenda)

Correct Answer: 1

Rationale 1: Donepezil (Aricept) is used to improve the ability to carry out activities of daily living. It decreases agitation and delusions and improves cognitive function.

Rationale 2: Adrenocorticotropic hormone is a natural hormone, but it has no known ability to treat Alzheimers.

Rationale 3: Olanzapine is used to treat the delusions, hallucinations, agitation, and combativeness characteristic of severe Alzheimers disease. It is not used for mild symptoms.

Rationale 4: Memantine is approved by the U.S. Food and Drug Administration for the treatment of moderate to severe AD.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-3

Question 3

Type: MCMA

The nurse is having a conversation with an older adult with Parkinsons disease. What would this patient most likely exhibit during the conversation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A low-pitched monotone voice

2. Bubbly, spirited discussion

3. Jumbled words that do not make sense

4. Angry, loud talk

5. Slurring and poor articulation of words

Correct Answer: 1,5

Rationale 1: Voice amplitude and vocal articulation are affected by the neuromuscular effects of Parkinsons disease. The voice becomes very monotone with progression of the disease. Patients need to be reminded to speak loudly.

Rationale 2: The changes associated with Parkinsons disease may make the patient appear to lack emotion or have a depressed affect.

Rationale 3: Muscular ability may make speech difficult, but the patient will retain cognitive ability, so communication should make sense.

Rationale 4: The voice tends to become muffled and softer.

Rationale 5: Voice amplitude and vocal articulation are affected by the neuromuscular effects of Parkinsons disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 4

Type: MCSA

A patient who was diagnosed with Parkinsons disease is exhibiting hypomimia. What will the nurse likely observe in this patient?

1. Slow movements of the arms and legs

2. Falling when attempting to step backward

3. Blank facial expression

4. Very slow talk

Correct Answer: 3

Rationale 1: Hypomimia does not affect the arms and legs.

Rationale 2: Patients with Parkinsons disease have difficulty with retropulsion, but this is not described as hypomimia.

Rationale 3: Bradykinesia and stiff facial muscles combine to create the masked facial expression associated with Parkinsons disease. This is hypomimia.

Rationale 4: Patients with Parkinsons do talk slowly, but this is not associated with hypomimia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 5

Type: MCSA

The nurse notes tremors and muscle rigidity in an older adult patient diagnosed with Parkinsons disease. Which medication would the nurse expect to administer to combat these symptoms?

1. Benztropine (Cogentin)

2. Dantrolene (Dantrium)

3. Riluzole (Rilutek)

4. Nitroglycerin (Nitro-bid)

Correct Answer: 1

Rationale 1: Benztropine is used to help manage the tremors and rigidity associated with Parkinsons disease.

Rationale 2: Dantrium is given to treat the spasiticity accompanying amyotrophic lateral sclerosis.

Rationale 3: Rilutek is the only durg with FDA approval for treating amyotrophic lateral sclerosis.

Rationale 4: Nitroglycerin (Nitro-bid) does not relieve tremors or muscle rigidity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-3

Question 6

Type: MCMA

A patient who is newly diagnosed with Huntingtons disease asks the nurse whether this disorder can be passed on to his future children. How should the nurse respond?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. There may be genetic concerns that should be discussed with the physician.

2. Your children will not be affected by the disease.

3. The disease is passed only through the mothers blood line.

4. Each child will have a 50% chance of inheriting the gene.

5. There is a strong chance that your children will be carriers, but they will only develop the disease if their mother is also a carrier.

Correct Answer: 1,4

Rationale 1: Huntingtons disease is a genetic disorder. Further discussion and information are necessary.

Rationale 2: Children have a 50% chance of inheriting the disease.

Rationale 3: Either sex can transmit and inherit Huntingtons disease.

Rationale 4: The chance that a child will inherit the disorder is 50%.

Rationale 5: Persons who inherit this faulty gene will develop the disorder. There is no carrier state.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-1

Question 7

Type: MCSA

The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). The nurse plans care based on which understanding of the patients prognosis?

1. The disease progresses slowly and is fatal.

2. The disease will progress over many years but the patients quality of life will be good.

3. The disease progresses rapidly but can be halted by drug therapy.

4. The disease will progress slowly and can be controlled by medication.

Correct Answer: 1

Rationale 1: The disease is slowly progressive and fatal and is characterized by weakness and wasting of muscles under voluntary control.

Rationale 2: Quality of life is profoundly affected by this disorder.

Rationale 3: Riluzole (Rilutek) is available to treat the disease, but it does not halt it. Death usually occurs due to respiratory failure.

Rationale 4: The disease is slowly progressive and cannot be controlled by medication.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-3

Question 8

Type: MCSA

Once amyotrophic lateral sclerosis (ALS) is diagnosed, what is the priority nursing activity?

1. Support the patient and family to meet physical and psychosocial needs.

2. Monitor for infection.

3. Assist the patient to avoid complications.

4. Assist the patient to adapt to the disease.

Correct Answer: 1

Rationale 1: Support for the patient and family should receive the highest priority for nursing intervention.

Rationale 2: It is important to monitor for infection, but this is not the most important intervention.

Rationale 3: It is important to assist the patient and family to avoid complications, but this is not the most important intervention.

Rationale 4: It is important to assist the patient and family to adapt to the disease, but this is not the most important intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-3

Question 9

Type: MCSA

A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis (MS). What is this patients priority health promotion activity?

1. Negotiate a regular schedule of 8-hour day shifts and consider applying for nursing positions that are less stressful and demanding.

2. Work as hard as possible now because it may not be possible later.

3. Continue to work as scheduled without making changes.

4. Leave employment as a nurse because of the need for complete bed rest.

Correct Answer: 1

Rationale 1: Multiple sclerosis (MS) is progressive and will be negatively affected by working long hours and enduring stressful shifts. It is important for this patient to plan a schedule that is less demanding and move now to a work environment that is less stressful for adapting to life with MS.

Rationale 2: Working as hard as possible now will not slow the progression of the disease. The nurse must make work life changes.

Rationale 3: Work life changes are necessary. The patient needs additional physical rest and a less stressful environment.

Rationale 4: There is no indication that the patient cannot continue employment as a nurse or that the patient needs complete bed rest.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-5

Question 10

Type: MCSA

Which test involving injection of a drug would the nurse anticipate being ordered to diagnose myasthenia gravis (MG)?

1. A Tensilon test

2. A computed tomography (CT) scan of the legs

3. A nerve stimulation study

4. Analysis of antiacetylcholine receptor antibodies

Correct Answer: 1

Rationale 1: This test involves intravenous administration of Tensilon. A positive response is an increase in muscle strength and is diagnostic of MG.

Rationale 2: A computed tomography (CT) scan of the legs is not indicated for this patient.

Rationale 3: The nerve stimulation study can be done to help diagnose MG but does not require a drug injection.

Rationale 4: An analysis of antiacetylcholine receptor antibodies can help diagnose MG, but it does not require a drug injection.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 23-2

Question 11

Type: MCMA

The nurse is assessing a patient with myasthenia gravis. Which findings would the nurse attribute to this disease?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Visual problems may be an early symptom.

2. Routine exercise provides an improvement in muscle strength.

3. There may be difficulty swallowing.

4. Muscle strength improves greatly with physical therapy.

5. There may be poor articulation in speaking.

Correct Answer: 1,3,5

Rationale 1: The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are affected and the patient experiences either diplopia (unilateral or bilateral double vision) or ptosis (drooping of the eyelid).

Rationale 2: Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles.

Rationale 3: Patients may have periods of dysphagia (difficulty swallowing).

Rationale 4: Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles, while rest improves function.

Rationale 5: Patients may have periods of dysarthria (problems with speech).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 12

Type: MCSA

A nurse working in a fertility clinic reviews the health history of a patient whose father had Huntingtons disease. What initial statement

by the nurse would best address this patients risk factors?

1. What do you know about testing for this disease?

2. Have you ever been tested for this disease?

3. Are you sure you want to have children?

4. Your child has a 50% chance of getting this disease.

Correct Answer: 1

Rationale 1: Sensitive issues such as genetic predisposition, counseling, and risk must be handled tactfully, and it would be important to begin the history with questions about the patients knowledge level. Assessing that initially can then lead to more in-depth questioning.

Rationale 2: This is important information, but is not the best initial question.

Rationale 3: The nurse should not impose his or her own belief system on the patient.

Rationale 4: Before stating facts, the nurse should assess the patients current knowledge.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-5

Question 13

Type: MCSA

A patients husband states, Ive noticed that my wife doesnt sleep well anymore and sometimes cant find the right words when were talking. Which is the most appropriate response by the nurse?

1. How long have you noticed these changes?

2. Does anyone in your family have Alzheimers disease?

3. These are common changes associated with age.

4. Do you think your spouse is depressed?

Correct Answer: 1

Rationale 1: Additional assessment is important for diagnostic purposes.

Rationale 2: The nurse should not automatically assume that the husbands statement indicates Alzheimers disease.

Rationale 3: Assuming these are age-related changes is inappropriate.

Rationale 4: Additional assessment should be made before the diagnosis of depression is suggested.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 14

Type: SEQ

A patient is hospitalized with amyotrophic lateral sclerosis (ALS), and the nursing diagnosis Spontaneous Ventilation, Impaired has been identified. In planning care for this patient, the nurse will prioritize the appropriate interventions. Rank the interventions, with the first being the most critical and the last the least critical.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Assess respiratory rate and lung sounds every 4 hours.

Choice 2. Monitor arterial blood gases to identify changes.

Choice 3. Maintain hydration and caloric intake.

Choice 4. Educate the patient about further treatment options.

Correct Answer: 1,2,3,4

Rationale 1: The nurse should assess the patient for respiratory distress. This frequent assessment will identify subtle changes before

they are reflected in ABG analysis.

Rationale 2: Monitoring ABGs assesses adequacy of gas exchange.

Rationale 3: Nutrition and hydration support respiratory function.

Rationale 4: The patient with ALS should be taught about the progression of the disease and the treatment options available at each stage of the illness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-3

Question 15

Type: MCSA

A home health nurse visits a patient with moderate Alzheimers disease who lives at home with the spouse. To meet the needs of the spouse, the nurse suggests which action?

1. Finding respite care to come into the home several days a week

2. Making arrangements for the patient to visit the local senior citizens center in the afternoon

3. Providing the patient with a list of daily activities to complete

4. Finding placement in a long-term care facility

Correct Answer: 1

Rationale 1: Patients with moderate Alzheimers disease generally are more confused, may demonstrate repetitive behavior, are less able to make simple decisions and adapt to environmental changes, and are often unable to carry out activities of daily living. The spouse needs opportunities for breaks from the demands of the patients care.

Rationale 2: An outing would be better suited for the patient with mild Alzheimers disease.

Rationale 3: A list of activities would be better suited for the patient with mild Alzheimers disease.

Rationale 4: Recommending placement in long-term care might be premature and is not up to the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-4

Question 16

Type: MCSA

A patient with Alzheimers disease has lost 5 pounds over the past month. What is the best nursing intervention to address this weight loss?

1. Provide a high-fiber diet.

2. Recommend referral to a nutritionist for tube feeding.

3. Make sure the patient is put on a mechanical soft diet.

4. Give the patient food choices from which to select.

Correct Answer: 1

Rationale 1: Nutritional goals include reducing constipation, which is addressed with a high-fiber diet and maintaining hydration.

Rationale 2: There is no indication that tube feeding is required at this point.

Rationale 3: There is no indication of a problem with the patients teeth or chewing/swallowing mechanisms.

Rationale 4: Because of altered mental status, the patient might or might not be able to state what food choices he or she prefers.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-4

Question 17

Type: MCSA

A patient complains of occasional periods of confusion and forgetfulness but reports a clear thought process most of the day. The symptoms have been gradually worsening. What is the best initial response by the nurse?

1. Have you started any new medications?

2. You probably have nothing to worry about. Its most likely stress-related.

3. Everybody has a few problems with memory as they get older.

4. You should probably have an MRI of your brain.

Correct Answer: 1

Rationale 1: Adverse effects of medication can be a cause of confusion and forgetfulness.

Rationale 2: A nurse should never discount the patients concerns about memory loss and confusion.

Rationale 3: This patient is concerned about the level of confusion and forgetfulness, so it is not likely to be just a few problems.

Rationale 4: The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the nurses scope of practice to recommend this testing.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-1

Question 18

Type: MCSA

A patient states, My doctor said sometimes I may have an on-and-off problem with this medication. What does that mean? How should the nurse respond?

1. The on times will be when your symptoms are under control; the off times are when you will have increased problems with symptom management.

2. There will be times when you are depressed (off) and when you are happy (on).

3. You will have to take breaks from this medicine by stopping (off) and starting it (on) again so you dont build up a tolerance to it.

4. The off-on phases are associated with your appetite.

Correct Answer: 1

Rationale 1: Patients taking Parkinsons drugs can experience episodes of hypomobility (off) when the dopamine/acetylcholine are imbalanced, and periods of symptom management (on) when these two neurotransmitters are in better balance.

Rationale 2: The onoff phenomenon has nothing to do with depressive episodes.

Rationale 3: The medication for Parkinsons should not be started and stopped.

Rationale 4: Appetite is not associated with on-off phases.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-3

Question 19

Type: MCMA

A patient with myasthenia gravis is taking pyridostigmine (Mestinon). When teaching about this medication, the nurse should instruct the patient to immediately report which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased weakness

2. Excessive salivation

3. Fever

4. Tooth pain

5. Increased difficulty swallowing

Correct Answer: 1,2,5

Rationale 1: An overdose or underdose of anticholinesterase drugs can lead to a myasthenic or cholinergic crisis. The goal of pharmacological therapy is to increase muscle tone; weakness after taking the medication should be reported as soon as possible to avoid a medical emergency.

Rationale 2: Excessive salivation is a sign of cholinergic crisis.

Rationale 3: Fever is not an adverse effect of pyridostigmine (Mesinon).

Rationale 4: Tooth pain is not an adverse effect of pyridostigmine (Mestinon).

Rationale 5: Increased difficulty swallowing is a sign of cholinergic crisis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-4

Question 20

Type: MCSA

The nurse is completing discharge teaching to a patient with a new diagnosis of myasthenia gravis (MG). What information should the nurse provide about the patients diet?

1. You should try to maintain a healthy weight for your height.

2. Your diet should include more fats.

3. You should get most of your calories from liquids.

4. There should be no difference in your diet from what you were eating prior to diagnosis.

Correct Answer: 1

Rationale 1: It is recommended that the MG patient maintain a weight as close as possible to what is recommended for the patients height and weight.

Rationale 2: There is no indication that increased fats are required.

Rationale 3: There is no reason that the majority of the patients calories should come from liquids.

Rationale 4: The diet must be adapted to accommodate the physical changes that occur with MG and can contribute to nutritional problems.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-4

Question 21

Type: MCMA

The nurse is providing community education about Parkinsons disease (PD) symptomology. Which information would the nurse include in this discussion?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pill-rolling motions are often seen in the hands.

2. Muscle stiffness is a common manifestation.

3. People with Parkinsons disease often complain that they move slowly.

4. Many people with PD are injured because they tend to fall more than others.

5. People with PD tend to have drooping of the eyelids.

Correct Answer: 1,2,3,4

Rationale 1: Tremor at resta pill-rolling motion of the thumb and fingersis usually the first manifestation of PD.

Rationale 2: Rigidity or muscle stiffness is a common finding and is associated with aching and discomfort.

Rationale 3: Bradykinesia or slowness of movement is one of the more disabling symptoms of PD.

Rationale 4: Postural disturbances result in falling forward or backward.

Rationale 5: Drooping eyelids are associated with myasthenia gravis, not PD.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-2

Question 22

Type: MCSA

The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What is the nurses primary focus of care?

1. Respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communicate

2. Providing gastrostomy feedings as soon as possible to build up muscle mass when motor functions return

3. Pain management and active range-of-motion (ROM) exercises

4. Administering immunosuppressants

Correct Answer: 1

Rationale 1: Manifestations of ALS include loss of both upper and lower motor neurons, resulting in loss of the muscles of respiration and swallowing. Atrophy of the tongue and facial muscles results in difficulty swallowing and the inability to communicate.

Rationale 2: Gastrostomy feedings may be needed as the disorder progresses and muscle function is permanently lost.

Rationale 3: Pain management is not part of the treatment of ALS. Active ROM exercises are instituted only if the patient is able; then passive ROM is initiated to stimulate circulation.

Rationale 4: Immunosuppressants are not part of the treatment of ALS.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-3

Question 23

Type: MCSA

Review the computerized charting record and identify the stage of Alzheimers disease (AD) of the patient described.

1. Mild

2. Preclinical

3. Moderate

4. Severe

Correct Answer: 1

Rationale 1: Mild AD is present when the patient has mild confusion about familiar places, memory loss, slowness and difficulty in accomplishing tasks, mood swings, and personality changes. In this patient, this stage is evidenced by the ability to do partial tasks and recognize the daughter, and by increasing agitation.

Rationale 2: Preclinical patients are physically healthy and alert but may have more memory loss than expected.

Rationale 3: Moderate AD is evidenced by the inability to recognize friends and family, language difficulties, hallucinations, delusions, and paranoia.

Rationale 4: Severe AD is evidenced by the patients total dependence on others, inability to communicate, and inability to recognize loved ones.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-2

Question 24

Type: MCSA

The nurse recognizes the results in this laboratory report as consistent with which disorder?

1. Myasthenia gravis

2. Parkinsons disease

3. Amyotrophic lateral sclerosis (ALS)

4. Alzheimers disease

Correct Answer: 1

Rationale 1: Laboratory results consistent with a diagnosis of myasthenia gravis include a positive edrophonium chloride (Tensilon) test, delayed nerve transmission during electromyography, and elevated levels of serum acetylchloine receptor antibodies.

Rationale 2: There are no diagnostic tests for Parkinsons disease.

Rationale 3: There are no diagnostic tests for ALS.

Rationale 4: The tests reported are not associated with AD diagnosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 23-2

Question 25

Type: MCSA

When interviewing a patient suspected of exhibiting signs of Parkinsons disease, the nurse shows an understanding of the diseases etiology by asking which question?

1. Is it painful to flex your chin to your chest?

2. Do you recall if any of your relatives had difficulty holding on to things with their hands?

3. Did your muscle weakness first occur in your arms or in your legs?

4. Did I understand correctly that your memory problems started about 5 years ago?

Correct Answer: 2

Rationale 1: The symptoms of multiple sclerosis include LHermittes sign, or a shocklike pain that results from flexion of the neck.

Rationale 2: In Parkinsons disease (PD), the lack of dopamine production leads to difficulty with movement, tremors, rigidity, and difficulty maintaining posture. It is thought that the disease process results from a complex interaction between genetic and environmental factors.

Rationale 3: Amyotrophic lateral sclerosis (ALS) symptoms first present in an arm in roughly half of the cases, with about 20% of the occurrences affecting a leg.

Rationale 4: Slow and insidious in onset, and ranging over a course of 3 to 20 years, Alzheimers disease progressively degrades cognitive function.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-1

Question 26

Type: MCSA

The nurse is conducting an informative session about Alzheimers disease (AD) for a local civic group. The nurse shows an understanding of the disorder by providing which information?

1. In AD, the central nervous system is unpredictably affected, resulting in a loss of communication and motor skills.

2. AD is a form of dementia that is caused by a lack of a brain chemical.

3. AD occurs when the persons own immune system attacks the cells of the body.

4. AD is a disease process that starts by affecting a persons memory and progresses toward the loss of reasoning abilities.

Correct Answer: 4

Rationale 1: Multiple sclerosis (MS), not AD, is a disease of the central nervous system that is unpredictable and can leave the patient unable to speak, walk, or write.

Rationale 2: AD is not caused by the lack of a chemical in the brain.

Rationale 3: Myasthenia gravis, not AD, is an autoimmune reaction that results from a malfunction in the immune system.

Rationale 4: The onset of Alzheimers disease begins with subtle lapses of memory, which gradually and progressively develop into a chronic loss of personality, recognition, reasoning, and independence.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-1

Question 27

Type: MCMA

The nurse explains to a patient who has been diagnosed with myasthenia gravis (MG) that this condition differs from amyotrophic lateral sclerosis (ALS) in that MG has which characteristics?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. It is usually fatal in 3 to 4 years after onset.

2. MG presents with shorter remissions as the disease progresses.

3. The onset of MG in women commonly occurs between 20 and 40 years of age.

4. Patients experience an increase of symptoms when exposed to sunlight, viral illness, and emotional stress.

5. MG produces involuntary twitching of the arms, legs, and tongue muscles.

Correct Answer: 2,3,4

Rationale 1: ALS is generally fatal in 3 to 4 years.

Rationale 2: As MG progresses, symptom-free periods decrease, and muscle weakness fluctuates from mild to severe.

Rationale 3: MG occurs at any age, although the age of onset is commonly 20 to 40 years of age for women and 60 to 80 years of age for men.

Rationale 4: Exposure to sunlight, viral illness, surgery, immunization, emotional stress, menstruation, and physical factors might trigger or worsen exacerbations.

Rationale 5: In ALS, symptoms include fasciculation (involuntary twitching) of the limb and tongue muscles.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-1

Question 28

Type: MCMA

The nurse is providing care to a patient with mysasthenia gravis (MG). The nurse would plan this care based on which characteristics of the disease?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Immunosuppressant therapy may be prescribed.

2. Exercise increases muscle strength.

3. Visual problems may be an early symptom.

4. Initial drug treatment often involves cholinesterase inhibitors.

5. Ptosis may be either unilateral or bilateral.

Correct Answer: 1,3,4,5

Rationale 1: Treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength.

Rationale 2: Exercise tends to fatigue muscles, while rest improves function.

Rationale 3: The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are affected.

Rationale 4: Cholinesterase inhibitor therapy is often the initial drug treatment for MG.

Rationale 5: The patient experiences either diplopia (double vision) or ptosis (drooping of the eyelid unilaterally or bilaterally).

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-3

Question 29

Type: MCSA

The nurse is assessing a patient who has been diagnosed with Parkinsons disease and documents that he is demonstrating bradykinesia. The nurse bases this on which observation?

1. The patient sloshes coffee out of his cup when eating breakfast.

2. The patient has difficulty initiating a walk to the bathroom.

3. The patient maintains his balance by holding on to the furniture.

4. The patients skin is moist and his clothing is damp.

Correct Answer: 2

Rationale 1: This action is likely due to the tremors that are a classic finding of PD rather than to bradykinesia.

Rationale 2: Bradykinesia, one of the more disabling symptoms of PD, refers to slowness of movement.

Rationale 3: Postural instability is a classic finding associated with PD but is not a characteristic of bradykinesia.

Rationale 4: Excessive sweating is an autonomic symptom associated with PD but is not a characteristic of bradykinesia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-2

Question 30

Type: MCMA

When providing education for a patient newly diagnosed with mild Alzheimers disease (AD) and the family, the nurse identifies which actions as signs that the disease is progressing in severity?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient repeatedly allows pots of water to boil dry.

2. The patient claims that the newspaper is not readable anymore.

3. The patient becomes agitated when old friends come to visit.

4. The patient is obsessive about how personal belongings are organized.

5. The patient develops a ravenous appetite, especially for carbohydrates.

Correct Answer: 1,2,3

Rationale 1: Poor judgment, memory loss, and difficulty completing familiar tasks are warning signs of progressively worsening AD.

Rationale 2: Loss of reading skills is a warning sign of progressively worsening AD.

Rationale 3: Changes in mood, behavior, or personality are warning signs of progressively worsening AD.

Rationale 4: Obsession with organization is not usually associated with Alzheimers.

Rationale 5: An increase in appetite is not usually associated with Alzheimers.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 23-5

Question 31

Type: MCSA

The nurse is preparing a patient diagnosed with amyotrophic lateral sclerosis (ALS) for discharge. The nurse realizes that interventions for which nursing diagnosis should be priority for this patient?

1. Impaired Urinary Elimination related to spastic or flaccid bladder

2. Disturbed Thought Processes related to cognitive decline

3. Alteration in Vision Acuity related to ocular muscle involvement

4. Ineffective Breathing Pattern related to neuromuscular dysfunction

Correct Answer: 4

Rationale 1: Impaired urinary elimination may be a problem for this patient but is not the priority.

Rationale 2: Patients with ALS do not have cognitive decline.

Rationale 3: Alterations in visual acuity are associated more closely with myasthenia gravis.

Rationale 4: ALS affects the neuromuscular function; the patient is at risk for respiratory dysfunction as a result of this disease process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 23-4

Question 32

Type: MCSA

The nurse is discussing the future with a patient recently diagnosed with amyotrophic lateral sclerosis (ALS). The patient asks about the possibility of continuing to work at the familys construction business. How should the nurse respond?

1. Can you do work that is less strenuous?

2. Is there a way you can switch over to the office side of the business?

3. This is a progressively debilitating disease. You need to think of ways to conserve your energy, not expend it.

4. Work as long at your job as you feel capable of keeping up with the demands it makes on you.

Correct Answer: 4

Rationale 1: While it is important to minimize stress and conserve energy, it is not necessary to alter ones life dramatically until the symptoms of the disease demand it.

Rationale 2: There is no evidence that working in the office will be less stressful than the physical work of the business.

Rationale 3: This is a progressively debilitating disease, but patients are encouraged to stay as active as possible for as long as possible.

Rationale 4: People with ALS do maintain careers and interests. They are encouraged to remain active for as long as possible.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 23-5

Question 33

Type: MCMA

During discharge planning, a nurse encourages a patient diagnosed with multiple sclerosis to engage in a regular exercise program. This recommendation is based on the knowledge that exercise will help the patient manage which problems associated with the disease?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Obesity

2. Muscle spasticity

3. Infection

4. Constipation

5. Fatigue

Correct Answer: 2,4,5

Rationale 1: Obesity is not a typical manifestation of this disease process.

Rationale 2: Patients should be encouraged to engage in a regular exercise program because exercise may help manage spasticity.

Rationale 3: Good nutrition can aid in resistance to infection.

Rationale 4: Patients should be encouraged to engage in a regular exercise program because exercise may help manage bowel and bladder problems.

Rationale 5: Patients should be encouraged to engage in a regular exercise program because exercise may help manage fatigue.

Global Rationale:

Cognitive Level: Applying

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