ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 44 : Care of Patients with Problems of the Peripheral Nervous System Questions
Question 1 of 5
A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
Question 2 of 5
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
Correct Answer: C
Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator may be needed, but emergency equipment should be available.
Question 3 of 5
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Correct Answer: A
Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. While it is important to avoid injury, this is not specific to corticosteroid use.
Question 4 of 5
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment is most important?
Correct Answer: D
Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty is necessary for an intact airway. Since the question does not include what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
Question 5 of 5
A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
Correct Answer: A
Rationale: Nothing should be placed under the cast to use for scratching, as this can cause skin damage or infection. The other statements show a good understanding of cast care instructions.