Nokea
A patient exhibits ptosis of both eyes and the provider orders edrophonium (Tensilon). The nurse notes immediate improvement of the ptosis. The nurse understands that this patient most likely has which disorder?
- A. Myasthenia gravis.
- B. Cerebral palsy.
- C. Multiple sclerosis.
- D. Muscle spasm.
Correct Answer: A
Rationale: The correct answer is A: Myasthenia gravis. Edrophonium is a reversible acetylcholinesterase inhibitor that improves muscle strength in patients with myasthenia gravis due to its ability to increase acetylcholine levels at the neuromuscular junction. The immediate improvement of ptosis after administration of edrophonium suggests a diagnosis of myasthenia gravis, a disorder characterized by muscle weakness and fatigability. Cerebral palsy (B) is a non-progressive neurological disorder not typically associated with ptosis and not responsive to edrophonium. Multiple sclerosis (C) is an autoimmune demyelinating disorder that does not typically present with ptosis. Muscle spasm (D) does not explain the ptosis and would not improve with edrophonium.
You may also like to solve these questions
The nurse is preparing to administer amoxicillin (Amoxil) to a patient and learns that the patient previously experienced a rash when taking penicillin. Which action will the nurse take?
- A. Administer the amoxicillin and penicillin available.
- B. Contact the provider to discuss using a different antibiotic.
- C. Ask the provider to order an antihistamine.
- D. Request an order for a beta-lactamase resistant drug.
Correct Answer: B
Rationale: The correct action is to contact the provider to discuss using a different antibiotic (Choice B) because the patient has a history of rash with penicillin. Since amoxicillin belongs to the same class of antibiotics as penicillin, there is a high risk of the patient experiencing a similar allergic reaction. By contacting the provider, the nurse can ensure the safety of the patient by exploring alternative antibiotics that are not in the same class as penicillin. This proactive approach prioritizes patient safety and minimizes the risk of an allergic reaction. Administering both amoxicillin and penicillin (Choice A) would be contraindicated due to the patient's history of rash. Asking for an antihistamine (Choice C) alone may not address the underlying issue of cross-reactivity between penicillin and amoxicillin. Requesting a beta-lactamase resistant drug (Choice D) is not necessary in this situation and does not address the patient's known allergy.
A nurse is providing discharge teaching for a patient who will be going home on cyclobenzaprine (Flexeril) prescribed for his acute musculoskeletal pain. The nurse will stress that the patient should avoid what?
- A. Taking antihistamines.
- B. Taking antiemetics.
- C. Taking antibiotics.
- D. Drinking alcohol.
Correct Answer: D
Rationale: The correct answer is D: Drinking alcohol. Cyclobenzaprine is a muscle relaxant that can cause drowsiness and dizziness. Alcohol can intensify these side effects, leading to impaired coordination and judgment. This can increase the risk of accidents and falls. It is important for the patient to avoid alcohol while taking cyclobenzaprine to prevent these adverse effects.
Choices A, B, and C are incorrect because there are no known interactions between cyclobenzaprine and antihistamines, antiemetics, or antibiotics that would pose a significant risk to the patient. It is essential to focus on the potential interactions that can have serious consequences, such as alcohol with cyclobenzaprine.
The nurse admits a patient to the unit and learns the patient has recently been diagnosed with chronic renal failure but has not informed the primary care provider of this diagnosis. What is the nurse's first priority?
- A. Maintain the patient's confidentiality.
- B. Administer medications ordered immediately.
- C. Provide teaching about chronic renal failure.
- D. Call the admitting physician immediately.
Correct Answer: D
Rationale: The correct answer is D: Call the admitting physician immediately. The nurse's first priority should be to inform the physician of the patient's recent diagnosis of chronic renal failure to ensure appropriate care and treatment. This action is crucial for the patient's safety and well-being. Maintaining confidentiality (A) is important but not the priority in this situation. Administering medications (B) should only be done after informing the physician about the diagnosis. Providing teaching (C) about the condition can wait until the physician is informed.
A nurse is caring for a six-year-old child who had surgery that morning. The child is awake and lying very still in bed. What should the nurse do?
- A. Use an “ouch†scale for pain assessment.
- B. Encourage the child to request pain medication when needed.
- C. Plan to administer pain medication if the child begins to cry.
- D. Ask the child to rate their pain on a scale of 1 to 10.
Correct Answer: A
Rationale: The correct answer is A: Use an "ouch" scale for pain assessment. This approach is appropriate for a six-year-old child as it uses a simple and understandable method to assess pain levels. The child may not verbalize pain or cry, so using a visual scale like an "ouch" scale can help the nurse accurately assess the child's pain level. Encouraging the child to request pain medication (B) assumes the child will always feel comfortable expressing their needs, which may not be the case. Planning to administer pain medication if the child cries (C) may lead to unnecessary medication administration if the child is not in pain. Asking the child to rate their pain on a scale of 1 to 10 (D) may be too complex for a young child to understand and communicate effectively.
A 70-year-old patient has just received a drug that can cause sedation. What would be the priority nursing diagnosis for this patient?
- A. Deficient Knowledge, unfamiliar with drug therapy.
- B. Ineffective health maintenance, need for medication.
- C. Risk for injury, related to adverse effect of the drug.
- D. Noncompliance, cost of the drug.
Correct Answer: C
Rationale: The correct answer is C: Risk for injury, related to adverse effect of the drug. This is the priority nursing diagnosis because the patient, being 70 years old and receiving a sedating drug, is at an increased risk for falls and other injuries due to sedation. It is crucial for the nurse to monitor the patient closely for signs of sedation and take appropriate measures to prevent potential harm.
Choice A (Deficient Knowledge) is not the priority as the immediate concern is the risk of injury. Choice B (Ineffective health maintenance) focuses on the need for medication, not the potential risk of injury. Choice D (Noncompliance) is not relevant in this situation as it pertains to the cost of the drug, not the immediate safety of the patient.