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Questions 158

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Question 1 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 2 of 5

Which complaint is frequently expressed by a client with macular degeneration?

Correct Answer: A

Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.

Question 3 of 5

A client who has been receiving Urokinase (UPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately?

Correct Answer: D

Rationale: Dark brown urine may indicate hematuria, a potential side effect of Urokinase, a thrombolytic agent. The nurse should withhold the medication and notify the physician immediately to assess for bleeding complications. Vitamin K is used for warfarin reversal, irrigation is inappropriate, and fluids won’t address the issue.

Question 4 of 5

The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?

Correct Answer: B

Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.

Question 5 of 5

An 8-year-old child comes to the physician's office complaining of swelling and pain in the knees. His mother says, 'The swelling occurred for no reason, and it keeps getting worse.' The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following would be important to include in the initial history?

Correct Answer: D

Rationale: Urinary tract symptoms are not commonly associated with Lyme disease. A fever of 103°F is not characteristic of Lyme disease. The rash that is associated with Lyme disease does not appear on the palms of the hands and the soles of the feet. Classic symptoms of Lyme disease include headache, malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly, conjunctivitis, sore throat, abdominal pain, and cough.

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