Nokea
The nurse is caring for a client with a history of myasthenia gravis.
- A. Which instruction is most important for a client with myasthenia gravis?
- B. Take pyridostigmine on an empty stomach.
- C. Avoid crowds to prevent infections.
- D. Restrict physical activity completely.
- E. Monitor blood pressure daily.
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, critical in myasthenia gravis due to immunosuppressive therapy. Pyridostigmine is taken with food, activity is encouraged, and blood pressure monitoring is not primary.
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The nurse is teaching family members how to correctly transfer a client who has right hemiplegia from the bed to a wheelchair. Which observation indicates that the family understands how to transfer the client?
- A. The wheelchair is placed parallel to the bed on the affected side.
- B. The family members lift the client up by having her place her arms around their necks.
- C. The wheelchair is placed at a 45-degree angle to the bed on the client's unaffected side.
- D. The family members ask for a trapeze bar for the client to use in the transfer.
Correct Answer: C
Rationale: Placing the wheelchair at a 45-degree angle on the unaffected side allows the client to pivot using their stronger left side, ensuring a safe transfer. Affected-side placement or neck lifting is unsafe, and a trapeze is unnecessary.
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
- A. disclose the information before the child knows or suspects.
- B. be comfortable with your sexual preference first.
- C. have the discussion in a quiet place where interruptions are unlikely.
- D. explain how your relationship with the child changes because of the discussion.
Correct Answer: D
Rationale: Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement
- B. Note the time from beginning to end
- C. Identify the pattern of breathing
- D. Determine if loss of bowel or bladder control occurs
Correct Answer: A
Rationale: Observe the sequence or types of movement. Noting movement types is critical for diagnosis and guiding treatment.
The nurse is teaching a client with a new diagnosis of asthma about using an albuterol inhaler. Which of the following statements by the client indicates a need for further teaching?
- A. I should shake the inhaler before using it.
- B. I should hold my breath for 10 seconds after inhaling.
- C. I should use the inhaler every 4 hours even if I feel fine.
- D. I should rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Using albuterol every 4 hours without symptoms is incorrect, as it is a rescue inhaler for acute symptoms, not maintenance. Options A, B, and D are correct: shaking ensures proper dose, holding breath maximizes absorption, and rinsing prevents oral thrush (though more relevant for steroids).