Nokea
The nurse is caring for a client with myasthenia gravis (MG) who is 14 weeks pregnant. Which of the following does the nurse understand about MG in the pregnant client?
- A. Most women with MG tolerate labor poorly unless they are in excellent physical health.
- B. Approximately 25% to 30% of neonates born to women with MG develop neonatal myasthenia.
- C. MG usually goes into remission with younger clients and causes exacerbation in older clients.
- D. Narcotics must be used with caution due to the risk of respiratory depression in clients who are already at risk for respiratory muscle weakness.
Correct Answer: B,D
Rationale: 25-30% of neonates may develop transient myasthenia, and narcotics require caution due to respiratory risks. Labor tolerance varies, and remission isn't age-dependent.
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The nurse is teaching a client how to stand on crutches. What information should the nurse give the client related to placement of the crutches?
- A. Place the crutches 3 inches to the front and side of the toes.
- B. Place the crutches 6 inches to the front and side of the toes.
- C. Place the crutches 15 inches to the front and side of the toes.
- D. Place the crutches 20 inches to the front and side of the toes.
Correct Answer: B
Rationale: The tripod position for crutches involves placing them 6 to 10 inches to the front and side of the toes, depending on body size, to ensure balance and support. Other distances are either too short or too long for effective crutch use.
The nurse is teaching a client who is preparing for discharge from the hospital after a total hip arthroplasty. Which statement by the client indicates the need for further teaching?
- A. I need to avoid twisting my body when I am standing.'
- B. I need to check my incision every day for signs of infection.'
- C. I should not sit in one position for a prolonged period of time.'
- D. I can cross my legs if it is more comfortable for me when I sit.'
Correct Answer: D
Rationale: After total hip arthroplasty, there are several measures that the client needs to take to ensure healing and protection and safety to the surgical site. Some hip precautions include not standing or sitting for prolonged periods of time, avoiding crossing the legs beyond the midline of the body, avoiding bending the hips more than 90 degrees, and avoiding twisting the body when standing. The client is also instructed to check the incision site daily for signs of infection (redness, heat, or drainage) and to contact the primary health care provider if signs of infection are noted.
The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client?
- A. The client will verbalize a reduction of pain.
- B. The client will report how to treat an infection.
- C. The client will be able to identify measures to prevent infection.
- D. The client will identify the presence of Braxton Hicks contractions.
Correct Answer: C
Rationale: The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of being invaded by pathogens after membrane rupture. The reduction of pain and Braxton Hicks contractions that occur during pregnancy are unrelated to the subject of infection. Reporting the treatment of infection indicates that an infection is present. Preventing an infection is a goal for the client who is at risk for infection.
The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?
- A. A gluten-free diet will need to be followed for life.
- B. A lactose-free diet will need to be followed temporarily.
- C. Added dietary sodium will help prevent episodes of celiac crisis.
- D. Supplemental vitamins, iron, and folate will prevent complications.
Correct Answer: A
Rationale: Celiac disease is characterized by intolerance to gluten, the protein component of wheat, barley, rye, and oats. The main nursing consideration with celiac disease is helping the child adhere to dietary management. The treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options 2 and 4 are true statements, but they do not answer the question that the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves with gluten withdrawal. Additional sodium does not prevent celiac crisis. Low levels of potassium, calcium, and magnesium are most likely to be present. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.
A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
- A. Exposure to heat
- B. Cigarette smoking
- C. Diet low in vitamin C
- D. Excessive water intake
Correct Answer: B
Rationale: Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors.