Nokea
An adult is thought to have myasthenia gravis. The nurse knows that which test is most likely to be ordered for the client?
- A. Lumbar puncture
- B. CT scan
- C. Cerebral angiogram
- D. Edrophonium (Tensilon) test
Correct Answer: D
Rationale: The edrophonium test, which temporarily improves muscle strength in myasthenia gravis, confirms diagnosis by enhancing neuromuscular transmission, unlike imaging or lumbar puncture.
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A woman who was recently diagnosed with multiple myeloma says to the nurse, 'Why did this happen to me? I've always been a good person. What did I do to deserve this?' What should the nurse do initially?
- A. Remind the client that she is not dying now and has some time left
- B. Call the chaplain to discuss why it happened to her
- C. Respond by recognizing how difficult this situation must be
- D. Tell her she didn't do anything to deserve it
Correct Answer: C
Rationale: Acknowledging the client's emotional distress validates her feelings, fostering therapeutic communication. Other responses dismiss or redirect her concerns.
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
A 15-year old is admitted following a motor vehicle accident. Examination reveals that the client has a closed head injury, a linear fracture of the temporal bone, a fracture of the mandible, and multiple abrasions. Upon admission, he is very drowsy. Which of the following orders would not be a part of the patient's care?
- A. Elevate the head 30°
- B. Apply Neosporin (neomycin) ointment to abrasions
- C. Polycillin (ampicillin) 500 mg IVPB q 6 hr
- D. Demerol (meperidine) 75 mg q 3-4 hr PRN pain
Correct Answer: D
Rationale: Demerol is contraindicated in head injuries due to its potential to mask neurological changes and increase intracranial pressure.
The nurse responds to a train derailment.
After making an initial assessment, which of the following clients should the nurse see FIRST?
- A. A pregnant woman who states that her clothing is wet.
- B. A young man with blood pulsating from a cut on the right leg.
- C. A preschool child who is screaming and crying uncontrollably.
- D. An unconscious woman with the right leg shorter than the left leg.
Correct Answer: B
Rationale: Strategy: Think ABCs. (1) requires further assessment, could be amniotic fluid or it could be urine (2) correct-indicates arterial bleeding; apply direct pressure; high risk for shock (3) stable patient (4) possible hip fracture, no indication of respiratory difficulty stated
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. There is an increased ability to see another's point of view.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusions.
Correct Answer: C
Rationale: Concrete operations (ages 7-11) involve logical, coherent thought about concrete events. Perspective-taking develops but is not primary, and abstract thinking is characteristic of later stages.