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Extract:


Question 1 of 5

The nurse is caring for a person admitted with myasthenia gravis. What should be included in the nursing care plan for this person?

Correct Answer: B

Rationale: Myasthenia gravis causes muscle weakness, increasing aspiration risk; checking swallowing reflexes ensures safe feeding. Other actions are irrelevant.

Extract:

You're able to elicit a Babinski's response in your 9-month-old patient.


Question 2 of 5

This is

Correct Answer: A

Rationale: A positive Babinski's response is normal in infants up to 12–24 months due to immature corticospinal tracts.

Extract:


Question 3 of 5

A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

Correct Answer: A

Rationale: Elevate the leg on 2 pillows. The first goal of nonpharmacologic interventions is to minimize edema of the affected extremity by leg elevation.

Question 4 of 5

The nurse is discussing hemophilia with a group of parents. Which child is most likely to have classic hemophilia?

Correct Answer: A

Rationale: Classic hemophilia (
A) is X-linked recessive; males whose mothers are carriers have a 50% chance of inheriting it, as males inherit the X chromosome from their mother.

Question 5 of 5

A client with end-stage renal disease received a renal transplant 2 weeks ago. Which of the following is an early sign of rejection of the transplant?

Correct Answer: B

Rationale: Early signs of renal transplant rejection include tenderness over the graft site, fever, and decreased urine output due to impaired kidney function. Increased urinary output is not associated with rejection, and while hypertension may occur, it is not a specific early sign.

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