Nokea
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
- A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis.
- B. This is of diagnostic value in only 25% of patients with myasthenia gravis.
- C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis.
- D. Tensilon works by blocking the action of acetylcholine at the myoneural junction.
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.
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The nurse is assessing the client receiving brimonidine eye drops. Which assessment findings will the nurse recognize as known side effects of brimonidine? Select all that apply.
- A. Blurred vision
- B. Ocular itching
- C. Ocular stinging
- D. Hearing loss
- E. Conjunctivitis
Correct Answer: A,B,C,E
Rationale: Brimonidine (Alphagan) is an alpha-2 adrenergic agonist; the nurse should recognize blurred vision, ocular itching, ocular stinging, and conjunctivitis as side effects of brimonidine. Hearing loss is not a side effect of brimonidine.
The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first?
- A. Teach the signs of increased intraocular pressure.
- B. Position the client as prescribed by the surgeon.
- C. Assess the eye for signs/symptoms of complications.
- D. Explain the importance of follow-up visits.
Correct Answer: B
Rationale: Positioning as prescribed (e.g., face-down) is critical to maintain gas tamponade efficacy and retinal reattachment. Teaching, assessment, and follow-up are secondary.
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.
The nurse is caring for multiple older adult clients with age-related visual changes. Which intervention should the nurse implement?
- A. Provide reading materials with boldface, normal-sized font.
- B. Lower the intensity of reading lamps to prevent glare.
- C. Provide the clients with a magnifying device for reading.
- D. Give clients printed materials that use similar, blended colors.
Correct Answer: C
Rationale: The nurse should provide a magnifying device for reading to enlarge words, making them easier to read. Normal-sized fonts, low-intensity lamps, and blended colors are less effective for visual changes.
The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.