Nokea
A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:
- A. Loss of the myelin sheath in portions of the brain and spinal cord
- B. An interruption in the transmission of impulses from nerve endings to muscles
- C. Progressive weakness and loss of sensation that begins in the lower extremities
- D. Loss of coordination and stiff 'cogwheel' rigidity
Correct Answer: B
Rationale: Myasthenia gravis is an autoimmune disorder causing impaired nerve-to-muscle communication, leading to muscle weakness, particularly in voluntary muscles.
You may also like to solve these questions
The nurse is caring for a client with a tracheostomy tube in place. During tracheostomy care, the nurse accidentally dislodges the tube. Which of the following actions should the nurse take FIRST?
- A. Insert a new tracheostomy tube immediately.
- B. Call for assistance from the respiratory therapist.
- C. Attempt to reinsert the dislodged tube.
- D. Cover the stoma with a sterile dressing.
Correct Answer: A
Rationale: immediate reinsertion of a tracheostomy tube is critical to maintain airway patency
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client could the nursing assistant care for?
- A. A client with Alzheimer's disease
- B. A client with pneumonia
- C. A client with appendicitis
- D. A client with thrombophlebitis
Correct Answer: A
Rationale: Alzheimer's patients require basic care, suitable for a nursing assistant.
The nurse is preparing a client with type 2 diabetes for a CT with contrast to evaluate diverticulitis with a possible mass. Which of the following medications on the client's medication list would be of concern to the nurse?
- A. fish oil
- B. warfarin (Coumadin)
- C. fluoxetine (Prozac)
- D. metformin (Glucophage)
Correct Answer: D
Rationale: Metformin should be held before and after contrast CT due to the risk of lactic acidosis if renal function is impaired by contrast dye.
A client with paranoid schizophrenia has an order for Thorazine (chlorpromazine) 400 mg orally twice daily. Which of the following symptoms should be reported to the physician immediately?
- A. Fever, sore throat, weakness
- B. Dry mouth, constipation, blurred vision
- C. Lethargy, slurred speech, thirst
- D. Fatigue, drowsiness, photosensitivity
Correct Answer: A
Rationale: Fever, sore throat, and weakness may indicate agranulocytosis, a serious side effect of chlorpromazine requiring immediate reporting.
The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.
- B. She sleeps quite a bit of the time.
- C. Her gums look too big for her teeth.
- D. She has gained about 10 pounds in the last six months.
Correct Answer: C
Rationale: Gingival hyperplasia is a common side effect of phenytoin therapy.