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Which ocular or facial signs/symptoms should the nurse expect to assess for the client diagnosed with myasthenia gravis?
- A. Weakness and fatigue.
- B. Ptosis and diplopia.
- C. Breathlessness and dyspnea.
- D. Weight loss and dehydration.
Correct Answer: B
Rationale: Ptosis and diplopia are hallmark ocular symptoms of myasthenia gravis due to neuromuscular weakness. General weakness, respiratory issues, and weight loss are less specific.
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The charge nurse observes the primary nurse interacting with a client. Which action by the primary nurse warrants immediate intervention by the charge nurse?
- A. The nurse explains the IVP diuretic will make the client urinate.
- B. The nurse dons nonsterile gloves to remove the client's dressing.
- C. The nurse administers a medication without checking for allergies.
- D. The nurse asks the UAP for help moving a client up in bed.
Correct Answer: C
Rationale: Administering medication without checking allergies risks allergic reactions, requiring immediate intervention. Diuretic explanation, glove use, and UAP assistance are appropriate.
Which collaborative health-care team member should the nurse refer the client to in the late stages of myasthenia gravis?
- A. Occupational therapist.
- B. Recreational therapist.
- C. Vocational therapist.
- D. Speech therapist.
Correct Answer: D
Rationale: Speech therapists address dysphagia and communication issues in late-stage myasthenia gravis. Other therapists are less relevant.
The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first?
- A. Draw a serum for CD4 and complete blood count STAT.
- B. Administer oxygen to the client via nasal cannula.
- C. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB.
- D. Obtain a sputum specimen for culture and sensitivity.
Correct Answer: B
Rationale: Oxygen administration addresses immediate hypoxia in PCP, a priority per ABCs. Labs, antibiotics, and sputum collection are secondary.
The nurse is describing the HIV virus infection to a client who has been told he is HIV positive. Which information regarding the virus is important to teach?
- A. The HIV virus is a retrovirus, which means it never dies as long as it has a host to live in.
- B. The HIV virus can be eradicated from the host body with the correct medical regimen.
- C. It is difficult for the HIV virus to replicate in humans because it is a monkey virus.
- D. The HIV virus uses the client's own red blood cells to reproduce the virus in the body.
Correct Answer: A
Rationale: HIV is a retrovirus that persists in the host, integrating into DNA. It cannot be eradicated, is not a monkey virus, and infects CD4 cells, not red blood cells.
The client is known to be HIV positive. Which data indicate to the nurse that the client has now progressed to the diagnosis of Acquired Immune Deficiency Syndrome (AIDS)?
- A. The client's CD4 count is 189.
- B. The client has an Hgb of 9.4 and Hct of 29.1.
- C. The client's chest x-ray show infiltrates.
- D. The client complains of a headache unrelieved by Tylenol.
Correct Answer: A
Rationale: A CD4 count below 200 defines AIDS in HIV-positive clients. Anemia, infiltrates, and headaches are non-specific.