Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:

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Question 1 of 5

Clients with myastherda gravis, Guillain - Barre Syndrome or amyothrophic sclerosis experience:

Correct Answer: C

Rationale: Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis (ALS) are all affected by various neuromuscular conditions that can lead to respiratory complications. These conditions can cause weakness in the muscles involved in breathing, leading to difficulties with coughing, clearing secretions, and maintaining adequate ventilation. This weakness can ultimately result in an increased risk of breathing difficulties, respiratory infections, and respiratory failure. Therefore, clients with these conditions require close monitoring and respiratory support to manage and prevent complications related to respiratory function.

Question 2 of 5

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?

Correct Answer: D

Rationale: A bleeding disorder is a contraindication for thoracentesis because the procedure involves inserting a needle through the chest wall into the pleural space to drain fluid. Individuals with a bleeding disorder are at an increased risk of bleeding complications during and after the procedure. It is important to ensure adequate clotting function before performing a thoracentesis to prevent excessive bleeding. If a client has a bleeding disorder, alternative diagnostic methods may need to be considered to minimize the risks associated with the procedure.

Question 3 of 5

A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below:

Correct Answer: B

Rationale: In a client with idiopathic thrombocytopenic purpura (ITP), a platelet count falling below 20,000/ul puts them at the greatest risk for cerebral hemorrhage. This is because the risk of spontaneous bleeding, especially in critical areas like the brain, significantly increases as platelet counts drop below this level. The brain is a sensitive organ, and even minor bleeds can have serious consequences. Therefore, it is crucial for healthcare providers to closely monitor platelet counts and promptly intervene to prevent life-threatening hemorrhage in clients with ITP.

Question 4 of 5

a school-age child is admitted in vaso-occlusive sickle cell crisis. the child's care should include which of the following?

Correct Answer: B

Rationale: In a vaso-occlusive sickle cell crisis, it is crucial to focus on adequate hydration and pain management. Hydration is essential to prevent further sickling of red blood cells, which can exacerbate tissue damage and pain. Pain management is a key aspect of care as vaso-occlusive crises often cause severe pain that requires prompt and effective treatment. Administering heparin is not indicated in a vaso-occlusive sickle cell crisis as it is primarily used for conditions like deep vein thrombosis. Correcting acidosis and replacing factor VIII are also not typically part of the management of a vaso-occlusive sickle cell crisis.

Question 5 of 5

the vital sign that the nurse should most certainly check before administering digoxin is:

Correct Answer: A

Rationale: Before administering digoxin, it is crucial for the nurse to check the patient's pulse rate. Digoxin is a medication commonly used to treat heart conditions such as atrial fibrillation and heart failure by increasing the strength and efficiency of the heart's contractions. However, digoxin can also cause adverse effects such as bradycardia (slow heart rate) or heart block. Therefore, it is important to assess the patient's pulse rate to ensure that it is within the safe range before administering digoxin.

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