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When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
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Which assessment is most essential before administering digoxin to an adult?
- A. Ask the client if he has chest pain.
- B. Take an apical pulse.
- C. Take the client's blood pressure.
- D. Ask the client if he is short of breath.
Correct Answer: B
Rationale: Taking an apical pulse ensures the heart rate is above 60 bpm, as digoxin can cause bradycardia, a critical safety check.
When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on
- A. recognizing findings of toxicity
- B. taking the medication at specified times
- C. increasing the dosage based on blood glucose
- D. distinguishing hypoglycemia from hyperglycemia
Correct Answer: B
Rationale: A regular interval between doses should be maintained since oral hypoglycemics stimulate the islets of Langerhans to produce insulin.
The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip.
- A. Which symptom will the nurse observe in a one-month-old with unilateral right hip dislocation?
- B. Limited adduction of the right leg.
- C. Uneven gluteal fold and thigh creases.
- D. Increase in length of the right limb.
- E. Internal rotation of the right leg.
Correct Answer: B
Rationale: Unilateral hip dislocation causes uneven gluteal folds and thigh creases, with deeper and longer folds on the affected side due to hip displacement. Limited abduction (not adduction), shortened limb length, and variable rotation are more typical findings.
The nurse is caring for a client with a history of bipolar disorder.
- A. Which client statement indicates a need for further teaching about lithium therapy?
- B. I’ll drink plenty of water every day.'
- C. I’ll have my blood levels checked regularly.'
- D. I can stop the medication if I feel better.'
- E. I’ll avoid eating foods high in sodium.'
Correct Answer: C
Rationale: Stating that the medication can be stopped when feeling better indicates a misunderstanding, as lithium requires consistent use to maintain therapeutic levels and prevent mood swings. Hydration, blood monitoring, and sodium awareness are correct.
An elderly client is admitted to the unit with a temperature of $100.2^{\circ}$, urinary specific gravity of 1.032, and a dry tongue. The nurse should anticipate an order for:
- A. An antibiotic
- B. An analgesic
- C. A diuretic
- D. An IV of normal saline
Correct Answer: D
Rationale: The symptoms (fever, high urinary specific gravity, dry tongue) indicate dehydration. IV normal saline is the priority to rehydrate. Antibiotics require infection confirmation, analgesics address pain, and diuretics worsen dehydration.