Nokea
The healthcare provider is caring for a client who has just been diagnosed with myasthenia gravis. Which symptom should the healthcare provider expect to observe?
- A. Muscle weakness
- B. Joint pain
- C. Vision changes
- D. Skin rash
Correct Answer: A
Rationale: Muscle weakness is a hallmark symptom of myasthenia gravis, a neuromuscular disorder characterized by impaired neuromuscular transmission. This results in muscle weakness, particularly in skeletal muscles that control eye movements, facial expressions, chewing, swallowing, and speaking. Joint pain (Choice B) is not a typical symptom of myasthenia gravis and is more commonly associated with conditions like arthritis. Vision changes (Choice C) may occur in conditions affecting the eyes, but they are not specific to myasthenia gravis. Skin rash (Choice D) is also not a typical manifestation of myasthenia gravis. Therefore, the correct answer is muscle weakness (Choice A).
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A healthcare professional is preparing to admit a client suspected of having pulmonary tuberculosis. Which of the following actions should the healthcare professional plan to perform first?
- A. Implement airborne precautions.
- B. Obtain a sputum culture.
- C. Administer antituberculosis medications.
- D. Recommend a screening test for close contacts.
Correct Answer: A
Rationale: The initial priority when admitting a client suspected of having pulmonary tuberculosis is to implement airborne precautions to prevent the spread of the disease. Airborne precautions include wearing a mask and placing the client in a negative pressure room. Obtaining a sputum culture is essential for confirming the diagnosis, but ensuring infection control measures come first to protect others. Administering antituberculosis medications is important but should be initiated after implementing necessary precautions. Recommending a screening test for close contacts is relevant but is a secondary concern compared to immediate infection control measures.
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?
- A. Curling ulcer
- B. Renal shutdown
- C. Metabolic acidosis
- D. Hemolysis of red blood cells
Correct Answer: C
Rationale: Corrected Rationale: Metabolic acidosis is a serious side effect of mafenide therapy that should be closely monitored. Mafenide can lead to metabolic acidosis due to its inhibition of carbonic anhydrase, resulting in the accumulation of carbonic acid. Curling ulcer (Choice A) is a stress-related mucosal lesion that occurs in the duodenum, primarily due to severe burns, not directly related to mafenide therapy. Renal shutdown (Choice B) is not a common side effect of mafenide therapy. Hemolysis of red blood cells (Choice D) is not a recognized side effect of mafenide cream application.
The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
- A. BP 142/88 mmHg
- B. 2+ edema of fingers and hands
- C. Radial pulse volume is +3
- D. Capillary refill time is 2 seconds
Correct Answer: B
Rationale: Edema, indicated by 2+ edema of fingers and hands, can impair blood flow and peripheral perfusion, leading to reduced oxygen saturation readings on a pulse oximeter. High blood pressure (choice A) would not directly affect oxygen saturation readings. Radial pulse volume (choice C) and capillary refill time (choice D) are more related to assessing circulation rather than contributing significantly to oxygen saturation readings.
When caring for a client with diarrhea due to Shigella, which of the following precautions should the nurse take?
- A. Wash hands before and after contact with the client
- B. Wear a surgical mask
- C. Use a face shield
- D. Wear a gown and gloves only
Correct Answer: A
Rationale: The correct precaution for Shigella infection is to wash hands thoroughly before and after contact with the client. Shigella is transmitted through the fecal-oral route, so hand hygiene is crucial in preventing its spread. Wearing a surgical mask or face shield is not necessary for Shigella as it is not primarily transmitted through respiratory droplets. While wearing a gown and gloves is important for standard precautions, the key precaution specific to Shigella is proper hand hygiene.
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?
- A. Lymphedema and nerve palsy
- B. Hearing loss and ataxia
- C. Headaches and vomiting
- D. Abdominal mass and weakness
Correct Answer: D
Rationale: Neuroblastoma, a common solid tumor in children, often presents with symptoms related to the mass effect it causes. Abdominal mass and weakness are classic signs of neuroblastoma due to the tumor originating in the adrenal glands near the kidneys and potentially compressing nearby structures. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more common in conditions affecting the central nervous system rather than neuroblastoma. Headaches and vomiting (Choice C) are nonspecific symptoms and are less commonly linked to neuroblastoma compared to the characteristic abdominal findings.