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 caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.
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Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
A client is admitted to the psychiatric unit after lavage and stabilization in the emergency room for an overdose of antidepressants. This is her third attempt in 2 years. The highest priority intervention at this time is to:
- A. Assess level of consciousness
- B. Assess suicide potential
- C. Observe for sedation and hypotension
- D. Orient to her room and unit rules
Correct Answer: B
Rationale: Suicide assessment is always appropriate for clients with a history of previous attempts or depression, because either of these factors places the client at high risk.
A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
- A. The fact is you are an alcoholic or you wouldn't be here.
- B. I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.
- C. If you can stop drinking when you want to, why don't you stop?
- D. It's good that you can stop drinking when you want to.
Correct Answer: B
Rationale: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.
A 5-year-old child cries continually in her bed. Her parents have been unsuccessful in assisting her in expressing her feelings. Which activity should the nurse provide the child to assist her in expressing her feelings?
- A. Books with colorful pictures
- B. Music
- C. Riding toys
- D. Puppets
Correct Answer: D
Rationale: Puppets allow expression of feelings and fears that otherwise could not be directly communicated, helping the child articulate emotions.
The nurse is caring for a client with a diagnosis of preterm labor. Which medication is most likely to be ordered?
- A. Betamethasone
- B. Terbutaline
- C. Magnesium sulfate
- D. All of the above
Correct Answer: D
Rationale: Betamethasone promotes fetal lung maturity terbutaline and magnesium sulfate are tocolytics to halt preterm contractions and magnesium may also provide neuroprotection. All are commonly ordered in preterm labor.