200 Nursezone Medical-surgical Nursing Final Coaching Part 1 (1 To 25)

The patient's increased fatigue, weakness, and difficulty breathing indicate a potential respiratory distress, which can be life-threatening. Providing adequate ventilatory support should be the first priority to ensure the patient's oxygenation and ventilation. Discontinuing cholinergic drugs, administering atropine, or increasing cholinergic drug doses may be appropriate interventions in certain situations, but they do not address the immediate need for ventilatory support.

The patient's ascending paralysis to the level of the waist suggests a possible neurologic emergency, such as Guillain-Barre syndrome. This condition can lead to respiratory distress and the need for intubation. Electrocardiographic monitoring electrodes are necessary to monitor the patient's cardiac status, as autonomic dysfunction can occur. Therefore, bringing electrocardiographic monitoring electrodes and an intubation tray into the client's room would be appropriate in this situation.

Parkinson's disease is an idiopathic syndrome, meaning its cause is unknown. It is characterized by disability from tremor and rigidity. This means that individuals with Parkinson's disease experience symptoms such as shaking/tremors and stiffness in their muscles, which can significantly impact their ability to move and perform daily activities. The disease is not caused by inflammation, an infectious agent like Cytomegalovirus, or the degeneration of the myelin sheath of peripheral nerves. The degeneration of nor-epinephrine-producing cells in the substantia nigra is also not a characteristic of Parkinson's disease.

The primary feature of Myasthenia Gravis is increasing weakness with sustained muscle contraction. This means that the patient experiences progressive muscle weakness and fatigue, particularly during activities that require continuous muscle use. This symptom is characteristic of the disease and distinguishes it from other conditions. The patient's complaint of increased fatigue and weakness, along with difficulty breathing, aligns with this primary feature of Myasthenia Gravis.

The Tensilon test was done to diagnose MG. The physician injected a test dose of Edrophonium, a short-acting cholinesterase inhibitor, to the patient. When an additional dose of 8 mg was injected, the patient suddenly lifted their weak hand without difficulty. This positive response indicates that the patient has myasthenia gravis, as Edrophonium temporarily improves muscle strength in individuals with MG. The Tensilon test is commonly used to confirm the diagnosis of MG.

The nurse is asking about a history of respiratory or gastrointestinal infection during the previous month because Guillain-Barre syndrome is often preceded by an infection, most commonly a respiratory or gastrointestinal infection. This information is important because it helps to establish a potential trigger for the development of Guillain-Barre syndrome.

The most appropriate nursing diagnosis for this client is "Impaired physical mobility related to generalized weakness" because the client is experiencing sudden onset of weakness, which can affect her ability to move and perform activities of daily living. This nursing diagnosis addresses the client's current physical condition and the potential impact it may have on her mobility.

The presence of fever and chills in a client with multiple sclerosis suggests an infection that has caused the exacerbation of their MS symptoms, leading to weakness. Infections can trigger or worsen MS symptoms, and the sudden onset of generalized weakness along with the presence of fever and chills indicates an infectious process. It is important to address and treat the infection to help alleviate the exacerbation of MS symptoms and improve the client's overall condition.

The correct answer is "Encourage caregivers to share their knowledge and experience with newly assigned health care staff." This is inappropriate because it does not align with the goal of helping the client achieve an optimal level of functioning. Sharing knowledge and experience with newly assigned staff may not be helpful in improving the client's condition or providing appropriate care.

The client's manifestations of severe nightmares, periods of confusion, and belief in a conspiracy can be symptoms of Alzheimer's disease. While Parkinson's disease primarily affects motor abilities, it can also lead to cognitive decline and dementia. However, the specific symptoms described in the situation are more commonly associated with Alzheimer's disease, which is characterized by memory loss, confusion, and paranoia.

The nurse observes the cardinal features of Parkinson's disease, which include freezing movement, flexed posture of the neck, trunk, and limbs, tremor at rest, and rigidity. These symptoms are commonly seen in patients with Parkinson's disease and can significantly impact their daily functioning and quality of life. Paranoia and hallucinations are not cardinal features of Parkinson's disease, although they may occur in some patients as a result of the disease or medication side effects.

Letting the patient void after giving preoperative medications may denote a violation of the bio-ethical principle of non-maleficence because it can increase the risk of aspiration during surgery. It is important to ensure that the patient's bladder is empty before surgery to minimize the risk of complications.

The nurse would incorporate the strategy of providing information, giving positive feedback, and encouraging relaxation in the plan of care to help the client cope with the illness of ascending paralysis and mechanical ventilation. This approach aims to empower the client with knowledge about their condition, which can reduce anxiety and improve their ability to cope. Giving positive feedback can boost the client's morale and motivation. Encouraging relaxation techniques can help the client manage stress and promote a sense of calmness.

The client gripping the arms of the chair to reduce hand tremors is an appropriate action for someone with Parkinson's disease. Tremors are a common symptom of the disease, and gripping onto something can help stabilize the hands. The other options are all potential areas where further teaching may be required. Range of motion exercises should be done daily, not just 3 times a week, to maintain flexibility and prevent muscle stiffness. The mattress being bouncy and soft may not provide enough support for someone with Parkinson's, who may have difficulty with balance and coordination. Sleeping with two piles of pillows under the head can cause strain on the neck and may not provide proper support for sleep.

Clients with Eaton-Lambert (Myasthenic) syndrome should be assessed for the development of cancer on a yearly basis. This is because myasthenia gravis (MG) can precede the development of cancer by many years. Regular assessments are important to detect any potential cancer development in these clients.

The assessments that are unique to delirium in this situation are intervals of lucidity, hyperkinetic behavior, and abrupt onset of symptoms. Impaired judgment and distorted perceptions can be seen in both dementia and delirium, so they are not unique to delirium.

Lactation is not a precipitating factor of multiple sclerosis. Pregnancy, physical injury, and emotional stress are known to be precipitating factors that can trigger the onset or exacerbation of MS symptoms. However, lactation, which is the production of breast milk after childbirth, is not typically associated with the onset or exacerbation of MS symptoms.

The correct answer is "Confront people who are making her life miserable and try to resolve it." This is not a recommended intervention for preventing exacerbations of MS. It is important for the patient to identify aggravating factors that lead to exacerbations, increase their body's resistance to illness with intake of citrus fruits, and avoid stressors such as tiring activities and having a negative outlook in life. However, confronting people who are making her life miserable may not be within the patient's control and may not necessarily prevent exacerbations of MS.

Adventitious breath sounds indicate abnormal lung sounds, such as crackles or wheezes, which can be a sign of respiratory distress or underlying lung pathology. In the context of a client with degenerative neurologic disease, the presence of adventitious breath sounds suggests a worsening of respiratory function and may indicate a need for further intervention or medical attention. Therefore, adventitious breath sounds would be considered the least optimal outcome for the client.

Small frequent feedings should be avoided. This is not an appropriate nursing intervention because the patient is emaciated as a result of dysphagia. Dysphagia is difficulty in swallowing, and in this case, it has caused the patient to become emaciated. Small frequent feedings are typically recommended for patients with dysphagia to prevent choking and aspiration. Therefore, avoiding small frequent feedings would not be beneficial for the patient's condition.

In a cholinergic crisis, there is an excessive accumulation of acetylcholine due to overmedication with cholinesterase inhibitors like pyridostigmine. This leads to excessive stimulation of cholinergic receptors throughout the body, resulting in symptoms such as weakness, difficulty breathing, and increased fatigue. Additionally, cholinergic crisis can cause gastrointestinal symptoms such as nausea, vomiting, and abdominal cramps. Apprehension may also occur due to the respiratory distress caused by the crisis. Therefore, the nurse can anticipate these signs and symptoms in a patient experiencing a cholinergic crisis.

The correct answer is "After using the catheter I should wash it thoroughly with soap and water and keep it in a clean, tightly sealed plastic bag". This statement denotes effective teaching because it emphasizes the importance of proper cleaning and storage of the catheter to prevent infection. Washing the catheter with soap and water helps to remove any bacteria or debris, and storing it in a clean, sealed bag helps to maintain its sterility. This demonstrates the client's understanding of the necessary steps for self-catheterization hygiene.

The most therapeutic intervention of the community health nurse when interacting with the client and the client's family in managing ALS is to instruct the patient on how to use a walker. This intervention helps the client maintain mobility and independence, which is crucial in managing the progressive decline in neurologic function associated with ALS. By providing instruction on using a walker, the nurse supports the client's optimal level of functioning and helps them adapt to their chronic neurologic deficits.

Poultry is the correct answer because Campylobacter jejuni, the organism most often implicated in Guillain-Barre syndrome, is commonly found in poultry. This suggests that consuming contaminated poultry products may increase the risk of developing the syndrome.

The nurse interprets that the reticular activating system and cerebral hemispheres are involved in chronic insomnia. The reticular activating system is responsible for regulating wakefulness and sleep-wake transitions, while the cerebral hemispheres play a role in controlling sleep patterns and maintaining a regular sleep-wake cycle. Dysfunction in these areas can lead to difficulty falling asleep or staying asleep, resulting in chronic insomnia.