Nokea
Which nursing action is best for controlling the symptoms of the client diagnosed with myasthenia gravis?
- A. Ensure that the client has regular bowel and bladder elimination.
- B. Administer each dose of medication at the precise scheduled time.
- C. Encourage the client to exercise twice daily for 30 minutes.
- D. Monitor the client's blood pressure every 4 hours.
Correct Answer: B
Rationale: Precise timing of pyridostigmine administration ensures consistent symptom control in myasthenia gravis by maintaining acetylcholine levels.
You may also like to solve these questions
The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
Which client statement indicates a need for further teaching about meningitis precautions?
- A. I'll wear a mask when visitors come.'
- B. My family should wash their hands frequently.'
- C. I can share my water bottle with my spouse.'
- D. I'll stay in my room to avoid spreading germs.'
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.
The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement? Rank in order of performance.
- A. Assess the client’s mouth.
- B. Loosen restrictive clothing.
- C. Administer phenytoin IVP.
- D. Turn the client to the side.
- E. Protect the client’s head from injury.
Correct Answer: E,B,C,D,A
Rationale: 1. Protect the client’s head (E): Prevents injury during convulsions. 2. Loosen restrictive clothing (B): Ensures airway and circulation. 3. Turn to the side (D): Prevents aspiration post-seizure. 4. Administer phenytoin (C): Stops the seizure after safety is ensured. 5. Assess the mouth (A): Done post-seizure to check for injury.
Which assessment finding is most important to consider before developing the client's care plan?
- A. The client's ability to perform activities of daily living
- B. The client's preferences for and dislikes of various foods
- C. The family members' views about nursing home placement
- D. The client's feelings about giving up independent living
Correct Answer: A
Rationale: The ability to perform ADLs determines the level of assistance needed, guiding the care plan for a client with Parkinson's disease.