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Questions 158

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Extract:


Question 1 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

Question 2 of 5

Which method of transmission would most likely result in contamination with botulism?

Question Image

Correct Answer: B, D

Rationale: Botulism is caused by Clostridium botulinum toxin, typically from contaminated food (e.g., perforated cans,
B) or wound contamination (
D). It is not transmitted person-to-person (
A), via mosquitoes (
C), goat saliva (E), or cat litter dust (F).

Question 3 of 5

The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?

Correct Answer: B

Rationale: A stable stroke client (hospitalized for two days) is appropriate for a nursing assistant, who can assist with basic care (e.g., hygiene, mobility). Recent surgery (
A), PCA morphine (
C), and new admissions (
D) require higher-level nursing skills.

Question 4 of 5

An 18-year-old client enters the emergency room complaining of coughing, chest tightness, dyspnea, and sputum production. On physical assessment, the nurse notes agitation, nasal flaring, tachypnea, and expiratory wheezing. These signs should alert the nurse to:

Correct Answer: B

Rationale: A tension pneumothorax is an accumulation of air in the pleural space. Important physical assessment findings to confirm this condition include cyanosis, jugular vein distention, absent breath sounds on the affected side, distant heart sounds, and lowered blood pressure. Asthma is a disorder in which there is an airflow obstruction in the bronchioles and smaller bronchi secondary to bronchospasm, swelling of mucous membranes, and increased mucus production. Physical assessment reveals some important findings: agitation, nasal flaring, tachypnea, and expiratory wheezing. Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung in the alveolar and interstitial tissue and results in consolidation. Specific assessment findings to confirm this condition include decreased chest expansion caused by pleuritic pain, dullness on percussion over consolidated areas, decreased breath sounds, and increased vocal fremitus. A pulmonary embolus is the passage of a foreign substance (blood clot, fat, air, or amniotic fluid) into the pulmonary artery or its branches, with subsequent obstruction of blood supply to lung tissue. Specific assessment findings that confirm this condition include tachypnea, tachycardia, crackles (rales), transient friction rub, diaphoresis, edema, and cyanosis.

Question 5 of 5

The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?

Correct Answer: A

Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.

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