Nokea
A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:
- A. Increased levels of the coagulation factors and a decrease in fibrinolysis
- B. An inadequate production of platelets
- C. An inadequate intake of folic acid during pregnancy
- D. An increase in fibrinolysis and a decrease in coagulation factors
Correct Answer: A
Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.
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The nurse is caring for a client with a history of myasthenia gravis. The nurse should assess the client for:
- A. Muscle weakness
- B. Joint stiffness
- C. Skin lesions
- D. Chest pain
Correct Answer: A
Rationale: Myasthenia gravis causes autoimmune destruction of acetylcholine receptors, leading to muscle weakness, especially in the eyes, face, and limbs, a key assessment finding.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube. The rationale for this therapy is to:
- A. Prevent systemic infection
- B. Promote diuresis
- C. Decrease ammonia formation
- D. Acidify the small bowel
Correct Answer: C
Rationale: Neomycin is an antibiotic, but this is not the rationale for administering it to a client in hepatic coma. Diuretics and salt-free albumin are used to promote diuresis in clients with cirrhosis of the liver. Neomycin destroys the bacteria in the intestines. It is the bacteria in the bowel that break down protein into ammonia. Lactulose is administered to create an acid environment in the bowel. Ammonia leaves the blood and migrates to this acidic environment where it is trapped and excreted.
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Fourth stage of labor
- B. Third stage of labor
- C. Transition stage of labor
- D. Second stage of labor
Correct Answer: C
Rationale: The transition stage is characterized by irritability, nausea, and strong contractions as the cervix completes dilation.
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
- A. Obtain vital signs
- B. Connect the client to the cardiac monitor
- C. Ask the client if he is still having chest pain
- D. Complete the history profile
Correct Answer: B
Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.