Nokea
The nurse is planning care for an adult who has myasthenia gravis. What should be included in the care plan?
- A. Plan to have the client bathe in the evening.
- B. Check the client's gag and swallowing reflexes before the client eats.
- C. Encourage frequent bathing.
- D. Encourage the client to be most active in the middle of the day.
Correct Answer: B
Rationale: Myasthenia gravis causes muscle weakness, risking aspiration; checking gag and swallowing reflexes before eating ensures safety, unlike bathing or activity timing.
You may also like to solve these questions
In addition to standard precautions, a nurse should implement contact precautions for which client?
- A. 60 year-old with herpes simplex
- B. 6 year-old with mononucleosis
- C. 45 year-old with pneumonia
- D. 3 year-old with scarlet fever
Correct Answer: A
Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
- A. Call a chaplain
- B. Deny the feelings
- C. Cite recovery statistics
- D. Listen to the client
Correct Answer: D
Rationale: Listen to the client. Therapeutic communications are based on attentive listening to expressed feelings, followed by questions about cultural beliefs if needed.
The nurse is teaching a client with a new diagnosis of hypothyroidism about levothyroxine (Synthroid). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should report chest pain to my doctor.
- C. I should avoid taking this with antacids.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping levothyroxine when thyroid levels are normal is incorrect, as hypothyroidism requires lifelong replacement therapy. Options A, B, and C are correct: empty stomach dosing improves absorption, chest pain may indicate overdose, and antacids interfere with absorption.
A student nurse caring for a client while wearing a gown and gloves in addition to following standard precautions.
The nurse should determine that care is appropriate if the student nurse performs which of the following activities?
- A. Gives isoniazid (INH) to a client with tuberculosis.
- B. Administers an IM injection to a client with rubella.
- C. Delivers a food tray to a client with hepatitis.
- D. Changes the dressing for a client with a draining abscess.
Correct Answer: D
Rationale: Strategy: Determine how the organism of each disease is spread. (1) requires airborne precautions, particulate respirator (2) requires droplet precautions, nurse should wear a mask (3) requires standard precautions (4) correct-requires contact precautions
A client who has a panic disorder is receiving paroxetine HCl (Paxil). The client has been taking the drug for one week and is still having severe panic attacks. The client tells the nurse that she thinks the drug is not working. What is the best response for the nurse to make?
- A. You should ask your physician for a different drug.
- B. The physician will probably add another drug to your regimen.
- C. You should stop taking the medication if it is not effective.
- D. It takes two to four weeks for Paxil to be effective.
Correct Answer: D
Rationale: Paroxetine, an SSRI, requires 2-4 weeks to reach therapeutic effect for panic disorder, explaining the continued symptoms.