Nokea
Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
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Before the client undergoes the craniotomy, the nurse inserts a urinary catheter. How far should the catheter be inserted if the client is a male?
- A. 2'' to 4'' (5 to 10 cm)
- B. 4'' to 6'' (10 to 15 cm)
- C. 6'' to 8'' (15 to 20 cm)
- D. 8'' to 10'' (20 to 25.5 cm)
Correct Answer: D
Rationale: For a male, the urinary catheter should be inserted 8'' to 10'' to reach the bladder adequately.
The client is diagnosed with a brain abscess. Which sign/symptom is the most common?
- A. Projectile vomiting.
- B. Disoriented behavior.
- C. Headaches, worse in the morning.
- D. Petit mal seizure activity.
Correct Answer: C
Rationale: Brain abscesses cause increased ICP, leading to headaches worse in the morning (C). Vomiting (A) is less specific, disorientation (B) is secondary, and petit mal seizures (D) are less common.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.
On the basis of the factors that cause the client to experience paroxysmal pain, which intervention is most appropriate to include in this client's care plan?
- A. Direct a fan toward the client's face.
- B. Avoid care that involves touching the client's face.
- C. Apply ice packs to the client's face.
- D. Apply warm facial compresses for pain.
Correct Answer: B
Rationale: Avoiding facial touch minimizes triggering paroxysmal pain in trigeminal neuralgia, which is sensitive to tactile stimuli.
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
- A. Perform a complete neurological assessment.
- B. Awaken the client every 30 minutes.
- C. Turn the client to the side and allow the client to sleep.
- D. Interview the client to find out what caused the seizure.
Correct Answer: C
Rationale: Post-seizure, the client is in a postictal phase with lethargy. Turning to the side (C) prevents aspiration and allows safe rest. Neurological assessment (A) can wait until the client is less lethargic, frequent awakening (B) is unnecessary if oriented, and interviewing (D) is not urgent.