Nokea
A 22-year-old woman has just been diagnosed with myasthenia gravis. She asks the nurse what causes this disease. The most accurate response from the nurse is
- A. This is a disease caused by a chromosomal defect in utero. It is a structural abnormality in the chromosome that causes nerve cells in your body to become inflamed and not function properly.'
- B. This is an autoimmune disease in which antibodies attack the muscles and muscle atrophy occurs. The muscles will become weak and begin to waste.'
- C. This is an autoimmune disease in which antibodies destroy acetylcholine at the neuromuscular junction. This prevents your muscles from contracting normally.'
- D. This is a hereditary condition caused by a recessive gene. It causes nervous tissue to be broken down, and damage occurs to the brain and spinal cord.'
Correct Answer: C
Rationale: Myasthenia gravis is an autoimmune disorder where antibodies attack acetylcholine receptors at the neuromuscular junction, impairing muscle contraction.
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During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
The nurse is preparing to administer insulin to a client with type 1 diabetes mellitus. The client is to receive 10 units of regular insulin and 20 units of NPH insulin. Which of the following actions by the nurse is correct?
- A. Draw up the NPH insulin first, then the regular insulin in the same syringe.
- B. Administer the regular insulin in one syringe and the NPH in another.
- C. Mix the regular insulin with the NPH insulin in a vial before drawing it up.
- D. Administer the regular insulin 30 minutes after the NPH insulin.
Correct Answer: A
Rationale: regular insulin is drawn up first, followed by NPH, to prevent contamination of the regular insulin with NPH
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.
The clinic nurse is seeing a client who suffers from caregiver strain due to caring for her elderly parents who have dementia and live with her. Which action by the nurse during the assessment is most important?
- A. ask the client about her support systems
- B. ask the client what she does for relaxation
- C. ask if her parents' insurance covers adult day care for them
- D. offer to give her a list of nursing homes to care for her parents
Correct Answer: A
Rationale: Assessing support systems identifies resources to alleviate caregiver strain, guiding interventions to reduce stress.
Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.