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: D
Rationale: Edrophonium (Tensilon) is a short-acting cholinesterase inhibitor used in the Tensilon test to aid in the diagnosis of myasthenia gravis. In patients with myasthenia gravis, there is a deficiency of acetylcholine at the neuromuscular junction, leading to muscle weakness. By inhibiting the breakdown of acetylcholine, edrophonium temporarily increases the availability of acetylcholine at the neuromuscular junction.
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The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What should the nurse recommend?
- A. Never heat a bottle in a microwave oven.
- B. Heat only 10 ounces or more.
- C. Always leave bottle top uncovered to allow heat to escape.
- D. Shake bottle vigorously for at least 30 seconds after heating.
Correct Answer: A
Rationale: The nurse should recommend never heating a bottle in a microwave oven. Microwaves do not heat liquids evenly, and there is a risk of creating hot spots in the formula, which can burn the baby's mouth and throat. It is safer to heat the formula by placing the bottle in warm water or using a bottle warmer to ensure uniform heating throughout.
Why place an undershirt between the skin and the Pavlik harness?
- A. To keep the skin moist
- B. To prevent infection caused by pins of the Pavlik harness
- C. To prevent skin abrasions and irritation by the harness
- D. To keep the skin clean
Correct Answer: C
Rationale: Placing an undershirt between the skin and the Pavlik harness is done to prevent skin abrasions and irritation caused by the harness rubbing directly against the skin. The undershirt acts as a protective layer, reducing the likelihood of skin sensitivity or damage due to the continuous contact with the harness. This is particularly important for infants or young children who may have delicate skin that is more prone to irritation. By using an undershirt, caregivers can help ensure greater comfort for the child while wearing the Pavlik harness and reduce the risk of any skin-related complications.
A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient's diet with:
- A. One beef cube and 8oz of tomato juice
- B. One beef cube and 16oz of tomato juice
- C. Four beef cubes and 8oz of tomato juice
- D. One beef cube and 12oz tomato juice
Correct Answer: D
Rationale: One beef cube typically contains about 800mg of sodium, and 8oz of tomato juice contains approximately 480mg of sodium. Therefore, to provide a total of 1,600mg of sodium daily, the nurse could supplement the patient's diet with one beef cube (800mg sodium) and 12oz of tomato juice (720mg sodium). This combination would effectively provide the required 1,600mg of sodium per day for the patient with abnormal sodium losses.
Patient S is a sexually active adolescent; which of the following instructions would be included in the preventive teaching plan about urinary tract infections?
- A. Drinking acidic juices
- B. Avoiding urinating before intercourse
- C. Wearing nylon underwear
- D. Wiping back to front
Correct Answer: A
Rationale: Drinking acidic juices, such as cranberry juice, can help make the urine more acidic, which can potentially prevent bacteria from sticking to the urinary tract walls and reduce the risk of urinary tract infections. It is important to note that while acidic juices can be beneficial in some cases, they should not be relied upon as the sole preventive measure for UTIs. Other important preventive measures include staying hydrated, practicing good hygiene, and urinating before and after intercourse.
A school nurse is conducting vision and hearing testing on fifth-grade children. Which level of prevention is the nurse demonstrating?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: B
Rationale: The school nurse conducting vision and hearing testing on fifth-grade children is demonstrating the secondary level of prevention. Secondary prevention involves identifying and treating health conditions early to prevent their progression. In this scenario, the nurse's aim is to detect any existing vision or hearing problems in the children at an early stage so that appropriate interventions can be initiated to prevent further impairment or complications. This aligns with the goals of secondary prevention, which focuses on early detection, prompt intervention, and minimizing the impact of a health condition.