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When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
- A. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon).
- B. Increased weakness.
- C. Diaphoresis.
- D. Increased salivation.
Correct Answer: A
Rationale: Improved muscle strength after edrophonium indicates myasthenic crisis, not cholinergic crisis, which involves excessive anticholinesterase effects.
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A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
- A. Consult the pharmacist regarding identification of the medications.
- B. Show pictures to the client from the Physician's Desk Reference to identify the medications.
- C. Consult the previous medical record and notify the physician regarding medications that must be ordered.
- D. Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Correct Answer: D
Rationale: Having medications brought in original vials ensures accurate identification, promoting safe administration.
Which of the following steps is the final step that is used during the physical assessment of the abdomen?
- A. Inspection
- B. Light palpation
- C. Deep palpation
- D. Percussion
Correct Answer: C
Rationale: The standard sequence for abdominal assessment is inspection, auscultation, percussion, and palpation (light then deep). Deep palpation is the final step to assess for organ size or abnormalities.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
- A. Administer an antacid.
- B. Notify the physician.
- C. Offer a light snack.
- D. Assess the pain characteristics.
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
A client with a history of pancreatitis is admitted with abdominal pain. The nurse should monitor the client for which of the following complications?
- A. Hypocalcemia.
- B. Hypernatremia.
- C. Hypotension.
- D. Hyperkalemia.
Correct Answer: A, C
Rationale: Pancreatitis can cause hypocalcemia (due to fat necrosis) and hypotension (due to fluid loss).