Nokea
Which assessment finding in a client with myasthenia gravis indicates a need for immediate intervention?
- A. Mild diplopia
- B. Difficulty chewing
- C. Weak hand grip
- D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: A low respiratory rate indicates potential respiratory failure in myasthenia gravis, requiring immediate intervention.
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Which client response depicts normal function of cranial nerve XI?
- A. A client wrinkling the forehead
- B. A client puffing out the cheeks
- C. A client sticking out the tongue
- D. A client shrugging the shoulders
Correct Answer: D
Rationale: Cranial nerve XI (spinal accessory) innervates the trapezius and sternocleidomastoid muscles, enabling shoulder shrugging.
The nurse is working with clients and their families regarding substance abuse. Which statement is the scientific rationale for teaching the children new coping mechanisms?
- A. The child needs to realize that the parent will be changing behaviors.
- B. The child will need to point out to the parent when the parent is not coping.
- C. Children tend to mimic behaviors of parents when faced with similar situations.
- D. Children need to feel like they are a part of the parent’s recovery.
Correct Answer: C
Rationale: Children often mimic parental behaviors (C), including unhealthy coping mechanisms. Teaching new strategies helps break this cycle. Other options misrepresent the child’s role or focus.
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.
The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply.
- A. Sleep with the head of the bed elevated.
- B. Keep a humidifier in the room.
- C. Use caution when performing oral care.
- D. Stay on a full liquid diet until seen by the HCP.
- E. Notify the HCP if developing a cold or fever.
Correct Answer: A,C,E
Rationale: Elevating the HOB (A) reduces ICP, cautious oral care (C) prevents surgical site disruption, and reporting infections (E) is critical due to infection risk. Humidifiers (B) are not standard, and a liquid diet (D) is unnecessary unless specified.