The nurse advises a patient with myasthenia gravis to
A. Perform physically demanding activities early in the day
B. Anticipate the need for weekly plasmapheresis treatments
C. Do frequent weight-bearing exercise to prevent muscle atrophy
D. Protect the extremities from injury due to poor sensory perception
A. Perform physically demanding activities early in the day
To prevent autonomic hyperreflexia, which nursing action will the home health nurse include in the
plan of care for a patient who has paraplegia at the t4 level?
A. Support selection of a high-protein diet
B. Discuss options for sexuality and fertility
C. Assist in planning a prescribed bowel program
D. Use quad coughing to strengthen cough efforts
C. Assist in planning a prescribed bowel program
Which assessment data for a patient who has guillain-barre syndrome will require the nurses most
immediate action?
A. The patients sacral area skin is reddened
B. The patient is continuously drooling saliva
C. The patient complains of severe pain in the feet
D. The patients blood pressure is 150/82
MSN 377 EXAM 4 (2024-2025)
,B. The patient is continuously drooling saliva
The nurse has administered a prescribed iv osmotic diuretic to an unconscious patient. Which
parameter should the nurse monitor to determine the medications effectiveness?
A. Blood pressure
B. Intracranial pressure
C. Oxygen saturation
D. Hemoglobin and hematocrit
B. Intracranial pressure
A patient who is unconscious has ineffective cerebral tissue perfusion and cerebral tissue swelling.
Which nursing intervention will be included in the plan of care?
A. Encourage coughing and deep breathing
B. Position the patient with knees and hips flexed
C. Keep the head of the bed elevated to 30 degrees
D. Cluster nursing interventions to provide rest periods
C. Keep the head of the bed elevated to 30 degrees
Multiple sclerosis
A chronic, progressive degenerative disorder of the cns. Characterized by disseminated demyelination
of nerve fibers in the brain and spinal cord
Myasthenia gravis
An autoimmune disease of the neuromuscular junction. Characterized by the fluctuating weakness of
certain skeletal muscle groups, which increases with muscle use.
MSN 377 EXAM 4 (2024-2025)
, Guillain-barre syndrome
Autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin
sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response,
and sudden muscle weakness
Spinal cord injury
Temporary or permanent alteration in the function of the spinal cord, caused by trauma or damage to
the spinal cord
Autonomic hyperreflexia (dysreflexia)
Massive, uncompensated cardiovascular response to stimulation of the sympathetic nervous system
Stimulation of the sensory receptors below the level of the cord lesion
- htn, bradycardia, pounding headache
Neurogenic shock
Unopposed psns stimulation and disruption of sns, causing bradycardia, vasodilation, and
hypotension.
Usually occurs with sci at t6 or above
Spinal shock
Spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury.
Intracranial pressure
The amount of pressure inside the skull controlled by the three essential components of pressure in
the skull: brain tissue, blood, csf
MSN 377 EXAM 4 (2024-2025)
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