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The nurse is caring for a client with a history of myasthenia gravis. The nurse should assess the client for:
- A. Muscle weakness
- B. Joint stiffness
- C. Skin lesions
- D. Chest pain
Correct Answer: A
Rationale: Myasthenia gravis causes autoimmune destruction of acetylcholine receptors, leading to muscle weakness, especially in the eyes, face, and limbs, a key assessment finding.
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A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:
- A. Irregular pulse
- B. Bradycardia
- C. Hypertension
- D. Chest pain
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.
A client in active labor asks the nurse for coaching with her breathing during contractions. The client has attended Lamaze birth preparation classes. Which of the following is the best response by the nurse?
- A. Keep breathing with your abdominal muscles as long as you can.
- B. Make sure you take a deep cleansing breath as the contractions start, focus on an object, and breathe about 16-20 times a minute with shallow chest breaths.
- C. Find a comfortable position before you start a contraction. Once the contraction has started, take slow breaths using your abdominal muscles.
- D. If a woman in labor listens to her body and takes rapid, deep breaths, she will be able to deal with her contractions quite well.
Correct Answer: B
Rationale: Lamaze childbirth preparation teaches the use of chest, not abdominal, breathing. In Lamaze preparation, every patterned breath is preceded by a cleansing breath; as labor progresses, shallow, paced breathing is found to be effective. It is important to assume a comfortable position in labor, but the Lamaze-prepared laboring woman is taught to breathe with her chest, not abdominal, muscles. When deep chest breathing patterns are used in Lamaze preparation, they are slowly paced at a rate of 6-9 breaths/min.
A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?
- A. Perform massage of the stoma three times a day.
- B. Include high-fiber foods in the diet, especially nuts.
- C. Limit fluid intake to prevent loose stools.
- D. Cleanse the peristomal skin meticulously.
Correct Answer: D
Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (A) is unnecessary, high-fiber foods like nuts (B) may cause blockages, and limiting fluids (C) risks dehydration.
The nurse is preparing to administer oral potassium chloride to an elderly client. Which action should the nurse take before administering the medication?
- A. Perform a fingerstick for morning glucose
- B. Assess for signs of hypocalcemia
- C. Withhold food for thirty minutes
- D. Check the creatinine level
Correct Answer: D
Rationale: Potassium chloride can worsen renal function in elderly clients. Checking the creatinine level assesses kidney function to ensure safe administration. Glucose hypocalcemia and withholding food are not directly related to potassium administration.
The nurse is teaching a client with a history of osteoarthritis about exercise. The nurse should tell the client to:
- A. Engage in low-impact activities
- B. Perform high-impact exercises
- C. Avoid all physical activity
- D. Lift heavy weights
Correct Answer: A
Rationale: Low-impact activities like swimming reduce joint stress in osteoarthritis, improving mobility and reducing pain.