Nokea
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.
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The nurse is caring for a client with a history of schizophrenia. The nurse should expect the client to have:
- A. Hallucinations
- B. Memory loss
- C. Tremors
- D. Joint pain
Correct Answer: A
Rationale: Schizophrenia is characterized by hallucinations, delusions, and disorganized thinking, with hallucinations being a common symptom.
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.
The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?
- A. Tomatoes
- B. Legumes
- C. Dried fruits
- D. Nuts
Correct Answer: A
Rationale: Tomatoes are a poor source of iron compared to legumes, dried fruits, and nuts, which are rich in iron. Tomatoes provide vitamin C, which aids iron absorption, but lack significant iron content.
The nurse is teaching a client with a history of osteoarthritis about exercise. The nurse should tell the client to:
- A. Engage in low-impact activities
- B. Perform high-impact exercises
- C. Avoid all physical activity
- D. Lift heavy weights
Correct Answer: A
Rationale: Low-impact activities like swimming reduce joint stress in osteoarthritis, improving mobility and reducing pain.
The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:
- A. The tail of the pancreas
- B. The head of the pancreas
- C. The body of the pancreas
- D. The entire pancreas
Correct Answer: B
Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.