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The nurse is assessing a patient with myasthenia gravis. Which are characteristics of this disease?
Standard Text: Select all that apply.
- Routine exercise provides an improvement in muscle strength.
- Visual problems may be an early symptom.
- There may be difficulty swallowing.
- Great improvement occurs in muscle strength with physical therapy.
- There may be poor articulation in speaking.
2.3.5
After returning from a plasmapheresis treatment, the nurse suspects that a patient with myasthenia gravis is demonstrating signs of electrolyte imbalances. What did the patient demonstrate to confirm the nurse’s suspicion?
Standard Text: Select all that apply.
- sluggish bowel sounds
- heart rate 92 and irregular
- onset of circumoral tingling
- blood pressure 148/90
- bilateral leg cramping
2.3.5
A 36-year-old patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include when teaching the patient about this medication?
Standard Text: Select all that apply.
- Avoid alcohol.
- Avoid exposure to sunlight.
- Use effective contraception.
- Expect the skin to turn orange.
- Have routine eye examinations.
1,2,3
A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)
a. “Avoid acetaminophen in over-the-counter medications.”
b. “It may take several weeks to become effective on pain.”
c. “Pregnancy and breast-feeding are not affected by MTX.”
d. “Stay away from large crowds and people who are ill.”
e. “You may find that folic acid, a B vitamin, reduces side effects.”
a,b,d,e
MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.
The nurse suspects that a patient has Parkinson disease. What did the nurse assess as early signs of this neurologic disease?
Standard Text: Select all that apply.
- fatigue
- cogwheel rigidity
- being “frozen”
- bilateral involvement
- a slight a rhythmic hand tremor
1,5
Rationale 1: Parkinson disease begins with subtle manifestations. Patients may complain of feeling tired and may move more slowly.
Rationale 2: Cogwheel rigidity is a later manifestation of PD.
Rationale 3: Being “frozen” is a later manifestation of PD.
Rationale 4: Bilateral involvement is a later manifestation of PD.
Rationale 5: Tremor at rest is usually the first manifestation experienced in PD.
Global Rationale: Parkinson disease begins with subtle manifestations. Patients may complain of feeling tired and may move more slowly. Tremor at rest is usually the first manifestation experienced in PD. Cogwheel rigidity, being “frozen,” and bilateral involvement are later manifestations
An industrial nurse is conducting a class on ways to prevent back pain. What should the nurse include when teaching about lifting heavy objects?
Standard Text: Select all that apply.
1. Spread the feet apart to broaden the base of support.
2. Use the legs to push when lifting.
3. Stand as closely as possible to the object to be moved.
4. Roll or push the object instead of lifting.
5. Bend at the waist over the center of gravity.
1,2,3,4
Global Rationale: The guidelines for proper body mechanics include spreading the feet apart to broaden the base of support; using the large muscles of the legs to push when lifting; positioning the body as close to the object as possible before lifting or moving it; sliding, rolling, pushing, or pulling an object rather than lifting it; and bending the knees and lifting up over one’s own center of gravity. Bending at the waist is not recommended.
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
a. Intermittent rigidity
b. Lip smacking
c. Sudden loss of muscle tone
d. Brief jerking of the extremities
e. Picking at clothing
f. Patting of the hand on the leg
b,e,f
A client with Paget’s disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Administering ibuprofen (Motrin)
b. Applying a heating pad
c. Providing a massage
d. Referring the client to a support group
e. Using a bed cradle to lift sheets off the feet
b,c
A nurse is providing education to a community women’s group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)
a. Cut down on tobacco product use.
b. Limit alcohol to two drinks a day.
c. Strengthening exercises are important.
d. Take recommended calcium and vitamin D.
e. Walk 30 minutes at least 3 times a week.
c,d,e
Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco should be totally avoided. Women should not have more than one drink per day.
The nurse is instructing a patient with a ruptured vertebral disk on self-care measures. What should the nurse include in this teaching?
Standard Text: Select all that apply.
1. Bend from the waist.
2. Wear low-heeled shoes.
3. Avoid twisting the back.
4. Sleep on a firm mattress.
5. Use a pillow under the knees when lying down.
2,3,4,5
Global Rationale: The patient should be instructed to wear low-heeled or flat shoes, avoid twisting the back, sleep on a firm mattress, and, when in the supine position, to flex the knees to approximately a 45-degree angle with a small pillow. Bending from the waist should be avoided.
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion
f. Exophthalmos
ANS: A, B, E
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this client’s plan of care? (Select all that apply.)
a. “Increase your intake of caffeinated beverages.”
b. “Incorporate physical exercise into your daily routine.”
c. “Avoid all alcoholic beverages.”
d. “Participate in a smoking cessation program.” e. “Increase your intake of fruits and vegetables.”
ANS: B, D, E
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
a. Bleeding
b. Infection
c. Hoarseness
d. Dysphagia
e. Seizures
ANS: C, D
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?
a. Side-rail pads d. Suction tubing b. Tongue blade e. Urinary catheter c. Oxygen mask f. Nasogastric tube
ANS: A, C, D
The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem?
Standard Text: Select all that apply.
- The incidence of AD increases with age.
- AD tends to run in families.
- AD is more common in men.
- AD is caused by a virus.
- AD is caused by environmental c
Correct Answer: 1,2
