Solutions
22. What does the nurse understand that patients with
myasthenia gravis, Guillain-Barré syndrome, and amyotrophic
lateral sclerosis share in common?
A. Progressive deterioration until death.
B. Deficiencies of essential neurotransmitters.
C. Increased risk for respiratory complications.
D. Involuntary twitching of small muscle groups. Correct
Answers C
A 76-yr-old patient with obstipation has a fecal impaction and is
incontinent of liquid stool. Which action should the nurse take
first?
A. Administer bulk-forming laxatives.
B. Assist the patient to sit on the toilet.
C. Manually remove the impacted stool.
D. Increase the patient's oral fluid intake. Correct Answers C
A home health nurse is visiting a patient with myasthenia gravis
and is discussing methods to minimize the risk of aspiration
during meals because of decreased muscle strength. Which
suggestion should the nurse give to the patient?
A. Swallow when the chin is tilted upward.
B. Eat within 15 minutes of taking medication.
C. Discuss eating foods that are easily chewed and swallowed.
D. Lay in bed with the head of the bed elevated no greater than
30 degrees. Correct Answers C
,A nurse is caring for a patient who just experienced a seizure.
While doing follow-up documentation, the nurse plans to
include which of the following items in the progress note?
SELECT ALL THAT APPLY.
A. How long the seizure lasted.
B. The patients admitting diagnosis
C. What the patient had for breakfast.
D. The body part where the seizure started.
E. Reports of unusual sounds or smells prior to the seizure.
Correct Answers A,D,E
A patient has a new prescription for bromocriptime (Parlodel), a
dopamine receptor agonist, may indicate a need for an
adjustment in the dose?
A. The patient has a chronic dry cough.
B. The patient has four loose stools in a day.
C. blood pressure is 90/46 mm Hg.
D. The patient develops a deep venous thrombosis. Correct
Answers C
A patient has just arrived on the postoperative surgical unit after
having a laparoscopic esophagectomy with graft placement for
treatment of esophageal cancer. Which nursing action should be
included in the postoperative plan of care?
A. Elevate the head of the bed to at least 30 degrees.
B. Start oral fluids when the patient has active bowel sounds.
C. Notify the physician immediately about bloody NG drainage.
D. Reposition the nasogastric (NG) tube if drainage stops or
decreases. Correct Answers A
, A patient has newly diagnosed multiple sclerosis and asks many
questions about the disease. When teaching the patient about
multiple sclerosis, the nurse, knowing the pathophysiology of
the disease, explains which of the following to the patient?
A. Multiple sclerosis is an untreatable viral disease that destroys
the basal ganglia in the brain.
B. Nerve impulses travel too fast over nerves that have lost their
myelin coat, overloading the brain.
C. Antibodies are produced against acetylcholine receptors,
resulting in blocked muscle contraction.
D. Causes gradual destruction of the myelin sheath of nerves in
the brain and spinal cord in genetically susceptible people.
Correct Answers D
A patient hospitalized with an abdominal wound infection on a
non-restricted diet has only been eating about 25% of meals and
states, "Nothing on the menu sounds good." Which action by the
nurse will be most effective in improving the patient's oral
intake?
A. Order six small meals daily.
B. Make a referral to the dietitian.
C. Teach the patient about high-calorie foods.
D. Have family members bring in favorite foods. Correct
Answers B
A patient is awaiting surgery for acute peritonitis. Which action
will the nurse plan to include in the preoperative care?
A. Position patient with the knees flexed.
B. Avoid use of opioids or sedative drugs.
C. Offer frequent small sips of clear liquids.