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Questions 158

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Question 1 of 5

A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:

Correct Answer: B

Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.

Question 2 of 5

A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?

Correct Answer: B

Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.

Question 3 of 5

A client's prenatal screening indicated that she has no immunity to rubella. She is now 10 weeks pregnant. The best time to immunize her is:

Correct Answer: A

Rationale: The rubella vaccine is made with attenuated virus and is given in the immediate postpartal period to prevent infection during pregnancy and subsequent adverse fetal and neonatal sequelae. Mothers are advised to prevent pregnancy for 3 months following immunization. Rubella infection during the second trimester may result in permanent hearing loss for the fetus. RhoGam is the drug generally administered at 28 weeks' gestation to Rh-negative women. It is contraindicated to administer rubella vaccine during pregnancy. RhoGam is the drug administered within 72 hours postpartum to Rh-negative women to prevent the development of antibodies to fetal cells.

Question 4 of 5

A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:

Correct Answer: B

Rationale: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.

Question 5 of 5

A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:

Correct Answer: A

Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.

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