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The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
- A. Administering anxiolytics
- B. Administering a ventilator
- C. Obtaining atropine sulfate
- D. Sedating the client
Correct Answer: C
Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator may be needed, but emergency equipment should be available.
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A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000 mm3, magnesium 0.8 mg/dL, and sodium 138 mEq/L. What action by the nurse is best?
- A. Advise the client to restrict fluids
- B. Assess the client for signs of infection
- C. Have the client add table salt to food
- D. Instruct the client on a magnesium supplement
Correct Answer: D
Rationale: Iron and magnesium deficiencies can exacerbate symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed based on the laboratory results.
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
- A. Bladder control
- B. Cognitive perception
- C. Respiratory system
- D. Sensory functions
Correct Answer: C
Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
- A. MG is an autoimmune problem in which nerves do not cause muscles to contract
- B. MG is an inherited destruction of peripheral nerve endings and junctions
- C. MG is contact-induced paralysis of specific cranial nerves
- D. MG is a viral infection of the dorsal root of sensory nerve fibers
Correct Answer: A
Rationale: MG is an autoimmune disorder in which nerve fibers are damaged, and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.
The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
- A. Delayed afferent nerve impulses
- B. Delayed efferent nerve impulses
- C. Desynthesis in upper extremities
- D. Slows nerve impulse transmission
Correct Answer: D
Rationale: Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
- A. Avoid having teeth pulled for 1 year
- B. Avoid heavy lifting for 6 months
- C. Do not use harsh chemicals on your face
- D. Inform your dentist of this procedure
Correct Answer: C
Rationale: The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the affected side to prevent injury. The other instructions are not necessary.