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A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.
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What finding signifies that children have attained the stage of concrete operations (Piaget)?
- A. Explores the environment with the use of sight and movement
- B. Thinks in mental images or word pictures
- C. Makes the moral judgment that 'stealing is wrong'
- D. Reasons that homework is time-consuming yet necessary
Correct Answer: C
Rationale: The stage of concrete operations is depicted by logical thinking and moral judgments.
B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.
Potential complication that can be possibly developed will be:
- A. Sepsis
- B. Hypovolemic
- C. Pain
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
As a client progresses through pregnancy, she develops constipation. What is the primary cause of this problem during pregnancy?
- A. Decreased appetite
- B. Inadequate fluid intake
- C. Prolonged gastric emptying
- D. Reduced intestinal motility
Correct Answer: D
Rationale: During pregnancy, hormonal changes and mechanical pressure reduce motility in the small intestine, enhancing water absorption and promoting constipation. Although decreased appetite, inadequate fluid intake, and prolonged gastric emptying may contribute to constipation, they aren't the primary cause.
The nurse is preparing to discharge a client who is receiving Nardil (phenelzine). The nurse should tell the client to:
- A. Wear protective clothing and sunglasses outside.
- B. Avoid medications containing pseudoephedrine.
- C. Drink six to eight glasses of water a day.
- D. Avoid foods that are high in purine.
Correct Answer: B
Rationale: Drug interactions between an MAOI and pseudoephedrine can result in hypertensive crisis. Answer A refers to the client receiving antipsychotic medications such as Thorazine, so it is incorrect. Answers C and D do not apply to MAOIs, so they are incorrect.