Nokea
When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.
- A. Bradycardia
- B. Increased diaphoresis
- C. Decreased lacrimation
- D. Bowel and bladder incontinence
- E. Absent cough and swallow reflex
- F. Sudden marked rise in blood pressure
Correct Answer: B,D,E,F
Rationale: Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria.
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Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks' gestation?
- A. Fetal heart monitor
- B. An adult stethoscope
- C. Bell of a stethoscope
- D. Ultrasound fetoscope
Correct Answer: D
Rationale: Toward the end of the first trimester, the fetal heart tones can be heard with an ultrasound fetoscope. Options 2 and 3 are not designed to adequately assess the fetal heart rate. A fetal heart monitor is used during labor or in other situations when the fetal heart rate needs continuous monitoring.
The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional interventions should the nurse be prepared to implement? Select all that apply.
- A. Assisting with arterial blood gases
- B. Assisting with a lumbar puncture
- C. Assessing cranial nerve functioning
- D. Assessing respiratory rate and rhythm
- E. Assessing pulmonary wedge pressure
- F. Assessing cognitive abilities, including memory
Correct Answer: C,D
Rationale: Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brainstem injury because the respiratory center is located in the brainstem. Options 1, 2, 5, and 6 are not necessary based on the data in the question.
The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?
- A. Discourage the client from walking.
- B. Increase the rate of the oxytocin infusion.
- C. Monitor the fetal heart rate every 30 minutes.
- D. Encourage upright or side-lying maternal positions.
Correct Answer: D
Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.
A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.