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A patient is admitted with a diagnosis of myasthenia gravis. What symptom should the nurse expect to find during the assessment?
- A. Joint pain
- B. Muscle weakness
- C. Loss of sensation
- D. Severe headache
Correct Answer: B
Rationale: The correct answer is B: Muscle weakness. Myasthenia gravis is characterized by muscle weakness due to an autoimmune attack on acetylcholine receptors at the neuromuscular junction. This leads to impaired muscle contraction and weakness, especially in the face, neck, and extremities. Joint pain (A) is not a typical symptom of myasthenia gravis. Loss of sensation (C) is more indicative of a sensory nerve disorder rather than a motor disorder like myasthenia gravis. Severe headache (D) is not a common symptom of myasthenia gravis; it is more likely to be associated with other conditions such as migraines or intracranial pathology.
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What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
A client with acute pancreatitis is experiencing severe abdominal pain. Which enzyme level should the nurse monitor closely?
- A. Serum amylase.
- B. Serum sodium.
- C. Serum calcium.
- D. Serum potassium.
Correct Answer: A
Rationale: The correct answer is A: Serum amylase. In acute pancreatitis, damaged pancreatic cells release amylase into the bloodstream, causing elevated serum amylase levels. Monitoring serum amylase helps in diagnosing and assessing the severity of pancreatitis.
Incorrect choices:
B: Serum sodium - Serum sodium levels are typically not directly affected by pancreatitis.
C: Serum calcium - While hypocalcemia can occur in severe pancreatitis, monitoring serum calcium is not as specific for pancreatitis diagnosis or severity assessment as serum amylase.
D: Serum potassium - Potassium levels may be affected in pancreatitis due to vomiting or dehydration, but monitoring serum potassium is not as specific to pancreatitis as serum amylase.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Tis refers to carcinoma in situ, meaning the cancer is limited to the surface layer of cells in the cervix.
2. N0 indicates no regional lymph node involvement.
3. M0 indicates no distant metastasis.
4. Therefore, the cancer is localized only to the cervix, making answer A correct.
Summary:
B: Incorrect - Does not address the staging information provided in Tis, N0, M0.
C: Incorrect - The staging information is already provided, and further testing may not be necessary at this stage.
D: Incorrect - Staging information does not indicate difficulty in determining the original site of the cancer.
In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?
- A. Serum creatinine
- B. White blood cell count
- C. Hemoglobin level
- D. Serum potassium
Correct Answer: C
Rationale: Rationale: The correct answer is C, hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in CKD patients with anemia. Monitoring hemoglobin levels helps assess the effectiveness of the therapy in improving anemia. If hemoglobin levels increase, it indicates the therapy is working.
Summary of incorrect choices:
A: Serum creatinine - This measures kidney function, not the effectiveness of erythropoietin therapy for anemia in CKD patients.
B: White blood cell count - Monitors immune function, not related to erythropoietin therapy for anemia.
D: Serum potassium - Important for monitoring electrolyte balance in CKD patients but not specific to assessing erythropoietin therapy effectiveness.
During an assessment, a healthcare professional suspects a client has cholecystitis. What is a common symptom of this condition?
- A. Right upper quadrant pain
- B. Left lower quadrant pain
- C. Generalized abdominal pain
- D. Epigastric pain
Correct Answer: A
Rationale: The correct answer is A: Right upper quadrant pain. Cholecystitis is inflammation of the gallbladder, typically caused by gallstones. The gallbladder is located in the right upper quadrant of the abdomen, so pain in this area is a common symptom. The pain may also radiate to the back or right shoulder. Choices B, C, and D are incorrect because they do not typically align with the specific location of the gallbladder or the characteristic pain associated with cholecystitis.