MSN Exam for Myasthenia Gravis

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1) The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:

1. Prostigmine (neostigmine)
2. Atropine (atropine sulfate)
3. Didronel (etidronate)
4. Tensilon (edrophonium)

2) Karina a client with myasthenia gravis is to receive immunosuppressive therapy. The nurse understands that this therapy is effective because it:

1. Promotes the removal of antibodies that impair the transmission of impulses
2. Stimulates the production of acetylcholine at the neuromuscular junction.
3. Decreases the production of autoantibodies that attack the acetylcholine receptors.
4. Inhibits the breakdown of acetylcholine at the neuromuscular junction.

3) Myasthenia gravis is due to ____ receptors being blocked and destroyed by antibodies.

1. Epinephrine
2. Nicotinic
3. Acetylcholine
4. Transient

4) A client with myasthenia gravis has been receiving Neostigmine (Prostigmin). This drug acts by:

1. Stimulating the cerebral cortex
2. Blocking the action of cholinesterase
3. Replacing deficient neurotransmitters
4. Accelerating transmission along neural swaths

5) The most significant initial nursing observations that need to be made about a client with myasthenia include:

1. Ability to chew and speak distinctly
2. Degree of anxiety about her diagnosis
3. Ability to smile an to close her eyelids
4. Respiratory exchange and ability to swallow

6) In making a diagnosis of myasthenia gravis Edrophonium HCI (Tensilon) is used. The nurse knows that this drug will cause a temporary increase in:

1. Muscle strength
2. Symptoms
3. Blood pressure
4. Consciousness

7) Helen, a client with myasthenia gravis, begins to experience increased difficulty in swallowing. To prevent aspiration of food, the nursing action that would be most effective would be to:

1. Change her diet order from soft foods to clear liquids
2. Place an emergency tracheostomy set in her room
3. Assess her respiratory status before and after meals
4. Coordinate her meal schedule with the peak effect of her medication, Mestinon

8) Myasthenia gravis reflects a deficiency in communication by _______________ because receptors for this neurotransmitter have been destroyed.

1. acetylcholine
2. norepinephrine
3. GABA
4. dopamine

9) While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

1. The client may be less sensitive to the effects of a neuromuscular blocking agent.
2. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.
3. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.
4. Pancuronium and succinylcholine both require cautious administration.

10) Which of the following is not an autoimmune disease?

1. Graves disease
2. Myasthenia gravis
3. Insulin-dependent diabetes mellitus
4. Alzheimer’s disease

11) A client with myasthenia gravis ask the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:

1. A genetic in the production acetylcholine
2. A reduced amount of neurotransmitter acetylcholine
3. A decreased number of functioning acetylcholine receptor sites
4. An inhibition of the enzyme ACHE leaving the end plates folded

12) The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

1. Eating large, well-balanced meals
2. Doing muscle-strengthening exercises
3. Doing all chores early in the day while less fatigued
4. Taking medications on time to maintain therapeutic blood levels

13) The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?

1. Visual disturbances, including diplopia
2. Ascending paralysis and loss of motor function
3. Cogwheel rigidity and loss of coordination
4. Progressive weakness that is worse at the day’s end

14) Helen is diagnosed with myasthenia gravis and pyridostigmine bromide (Mestinon) therapy is started. The Mestinon dosage is frequently changed during the first week. While the dosage is being adjusted, the nurse’s priority intervention is to:

1. Administer the medication exactly on time
2. Administer the medication with food or mild
3. Evaluate the client’s muscle strength hourly after medication
4. Evaluate the client’s emotional side effects between doses

15) The initial nursing goal for a client with myasthenia gravis during the diagnostic phase of her hospitalization would be to:

1. Develop a teaching plan
2. Facilitate psychologic adjustment
3. Maintain the present muscle strength
4. Prepare for the appearance of myasthenic crisis

16) A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

1. Getting too little exercise
2. Taking excess medication
3. Omitting doses of medication
4. Increasing intake of fatty foods

17) Jane, a 20- year old college student is admiited to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

1. Brief exaggeration of symptoms
2. Prolonged symptomatic improvement
3. Rapid but brief symptomatic improvement
4. Symptomatic improvement of just the ptosis

18) Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirmed by:

1. Kernigs sign
2. Brudzinski’s sign
3. A positive sweat chloride test
4. A positive edrophonium (Tensilon) test

19) A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine?

1. Ulcerative colitis
2. Blood dyscrasia
3. Intestinal obstruction
4. Spinal cord injury

20) The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent off urine and stool. What is your best first action at this time?

1. Administer an acetaminophen suppository.
2. Notify the physician immediately.
3. Recheck vital signs in 1 hour.
4. Reschedule patient’s physical therapy.

Answers and Rationales

1. A. Prostigmine (neostigmine). Protigmine is used to treat clients with myasthenia gravis. Atropine (atropine sulfate) is incorrect because it is used to reverse the effects of neostigmine. Didronel (etidronate)is incorrect because the drug is unrelated to the treatment of myasthenia gravis. Tensilon (edrophonium) is incorrect because it is the test for myasthenia gravis.
2. C. Decreases the production of autoantibodies that attack the acetylcholine receptors. Steroids decrease the body’s immune response thus decreasing the production of antibodies that attack the acetylcholine receptors at the neuromuscular junction
3. C. Acetylcholine 
4. B. Blocking the action of cholinesterase
5. D. Respiratory exchange and ability to swallow . Muscle weakness can lead to respiratory failure that will require emergency intervention and inability to swallow may lead to aspiration
6. A. Muscle strength. Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in client who have the disease and is therefore an effective diagnostic aid.
7. D. Coordinate her meal schedule with the peak effect of her medication, Mestinon. Dysphagia should be minimized during peak effect of Mestinon, thereby decreasing the probability of aspiration. Mestinon can increase her muscle strength including her ability to swallow.
8. A. acetylcholine 
9. D. Pancuronium and succinylcholine both require cautious administration. The nurse must cautiously administer pancuronium, succinylcholine, and any other neuromuscular blocking agent to a client with myasthenia gravis. Such a client isn’t less sensitive to the effects of a neuromuscular blocking agent. Either succinylcholine or pancuronium can be administered in the usual adult dosage to a client with myasthenia gravis.
10. D. Alzheimer’s disease 
11. C. A decreased number of functioning acetylcholine receptor sites 
12. D. Taking medications on time to maintain therapeutic blood levels. Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.
13. D. Progressive weakness that is worse at the day’s end . The client with myasthenia develops progressive weakness that worsens during the day. Visual disturbances, including diplopia is incorrect because it refers to symptoms of multiple sclerosis. Ascending paralysis and loss of motor function is incorrect because it refers to symptoms of Guillain Barre syndrome. Cogwheel rigidity and loss of coordination is incorrect because it refers to Parkinson’s disease.
14. C. Evaluate the client’s muscle strength hourly after medication. Peak response occurs 1 hour after administration and lasts up to 8 hours; the response will influence dosage levels.
15. C. Maintain the present muscle strength. Until diagnosis is confirmed, primary goal should be to maintain adequate activity and prevent muscle atrophy
16. C. Omitting doses of medication. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.
17. C. Rapid but brief symptomatic improvement . Tensilon acts systemically to increase muscle strength; with a peak effect in 30 seconds, It lasts several minutes.
18. D. A positive edrophonium (Tensilon) test 
19. C. Intestinal obstruction . Anticholinesterase agents such as pyridostigmine are contraindicated in a client with a mechanical obstruction of the intestines or urinary tract, peritonitis, or hypersensitivity to anticholinesterase agents. Ulcerative colitis, blood dyscrasia, and spinal cord injury don’t contraindicate use of the drug.
20. B. Notify the physician immediately.The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need incubation and mechanical ventilation. The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen. This patient’s vital signs need to be re-checked sooner than 1 hour. Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization