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Question 1 of 5

The nurse caring for a client with myasthenia gravis is reviewing the nursing care plan. Which is recognized as the priority nursing diagnosis?

Correct Answer: C

Rationale: Clients with myasthenia gravis have problems with the muscular activity of breathing. Answers A, B, and D are not the priority, so they are wrong.

Question 2 of 5

The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?

Correct Answer: C

Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.

Question 3 of 5

A young adult has been diagnosed with Type 1 diabetes mellitus. The client asks how his condition differs from that of his grandmother who has Type 2 diabetes mellitus. What should the nurse include when replying?

Correct Answer: A

Rationale: Type 1 diabetes involves autoimmune destruction of pancreatic beta cells, causing insulin deficiency; Type 2 involves insulin resistance. Insulin may be used in Type 2, and diet or progression are not defining factors.

Question 4 of 5

An older adult client is to receive an antibiotic, gentamicin. What diagnostic finding indicates the client may have difficulty excreting the medication?

Correct Answer: B

Rationale: An elevated serum creatinine indicates reduced renal function. Reduced renal function will delay the excretion of many medications.

Question 5 of 5

The physician has prescribed Elavil(amitriptyline) for a client with depression. The nurse should continue to monitor the client's mood because the maximal effects of tricyclic antidepressant medication does not occur for:

Correct Answer: C

Rationale: Tricyclic antidepressants like amitriptyline take 2-4 weeks to reach maximal therapeutic effect.

Choices A and B are too short, and D is excessively long.

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