Nokea
The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?
- A. Joint pain following administration of the medication
- B. Feelings of faintness, dizziness, hypotension, and signs of flushing in the client
- C. A decrease in muscle strength within 30 to 60 seconds following administration of the medication.
- D. An increase in muscle strength within 30 to 60 seconds following administration of the medication
Correct Answer: C
Rationale: The correct answer is C because in myasthenia gravis, which is characterized by muscle weakness and fatigue, the administration of edrophonium will temporarily improve muscle strength due to increased availability of acetylcholine at the neuromuscular junction. This improvement should be noted within 30 to 60 seconds after the administration of the medication.
Choice A is incorrect because joint pain is not a typical response to edrophonium in the context of myasthenia gravis.
Choice B is incorrect because feelings of faintness, dizziness, hypotension, and flushing are more indicative of a cholinergic crisis, which occurs when too much edrophonium is administered.
Choice D is incorrect because an increase in muscle strength post-edrophonium administration would not be expected in a client with myasthenia gravis.
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Which patient should be monitored most closely for dehydration?
- A. The 50-year-old with an ileostomy
- B. The 72-year-old with diabetes mellitus
- C. The 19-year-old with chronic asthma
- D. The 28-year-old with a broken femur
Correct Answer: A
Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis, 'Risk for Aspiration related to reduced level of consciousness.' The nurse documents this nursing diagnosis as correct based on the understanding that which of the following is a characteristic of this type of diagnosis?
- A. Is written as a two-part statement
- B. Describes human response to a health problem
- C. Describes potential for enhancement to a higher state
- D. Made when not enough evidence supports the problem
Correct Answer: A
Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.
Which of the following outcomes would indicate successful treatment of diabetes insipidus?
- A. Fluid intake of less than 2,500mL in 24 hours
- B. Urine output of more than 200mL/hour
- C. Blood pressure of 90/50mmHg
- D. Pulse rate of 126 beats/min
Correct Answer: A
Rationale: The correct answer is A because successful treatment of diabetes insipidus aims to reduce excessive urine output and dehydration. A fluid intake of less than 2,500mL in 24 hours indicates proper control of fluid balance.
Choice B is incorrect because urine output of more than 200mL/hour suggests ongoing excessive fluid loss, which is not indicative of successful treatment.
Choice C is incorrect as a blood pressure of 90/50mmHg is low and may indicate hypotension, which is not a specific indicator of successful diabetes insipidus treatment.
Choice D is incorrect because a pulse rate of 126 beats/min is not a direct marker of diabetes insipidus treatment success.
In summary, the correct indicator of successful treatment of diabetes insipidus is a reduction in fluid intake, option A, as it signifies improved fluid balance and hydration status.
The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?
- A. Avoiding the use of recreational drugs and alcohol
- B. Refraining from telling anyone about the diagnosis
- C. Following safer-sex practices
- D. Telling potential sex partners about the diagnosis, as required by the law
Correct Answer: C
Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy.
Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS.
Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent.
Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.
Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient’s accomplishments without a time
- A. restriction.
- B. It is a realistic statement predicting any negative responses to treatments.
- C. It is a broad statement describing a desired change in a patient’s behavior.
- D. It is a measurable change in a patient’s physical state.
Correct Answer: D
Rationale: Step 1: A goal should be measurable to track progress effectively.
Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome.
Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound.
Step 4: Other choices lack the specificity and measurability required for a clear goal.
Step 5: Choice A talks about restriction, which is not directly related to understanding a goal.
Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal.
Step 7: Choice C is vague and lacks the specificity of a measurable outcome.