the nurse is caring for a client with myasthenia gravis which symptom is most important for the nurse to report to the healthcare provider
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Nursing Elites

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HESI Test Bank Medical Surgical Nursing

1. The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?

Correct answer: B

Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.

2. The nurse is teaching a client with gastroesophageal reflux disease (GERD) about dietary modifications. Which food should the client avoid?

Correct answer: C

Rationale: The correct answer is C: Coffee. Coffee should be avoided by clients with GERD as it can relax the lower esophageal sphincter, leading to an increase in GERD symptoms. Choices A, B, and D are not directly associated with worsening GERD symptoms and can be included in moderation in the diet of a client with GERD.

3. The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?

Correct answer: C

Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.

4. A client is admitted to the emergency department with symptoms of arm numbness, chest pain, and nausea/vomiting. The examining healthcare provider believes that the client has experienced an acute myocardial infarction (AMI) within the past three hours and would like to initiate tissue plasminogen activator (tPA) therapy. Which client history findings contraindicate the use of tPA?

Correct answer: B

Rationale: A history of cerebrovascular hemorrhage is a contraindication for tPA therapy due to the risk of bleeding. Choice A is incorrect because treating hypoglycemia with an oral hypoglycemic agent is not a contraindication for tPA therapy. Choice C is incorrect as age and family history of MI do not contraindicate the use of tPA. Choice D is incorrect as being intolerant of medication containing aspirin is not a contraindication for tPA therapy.

5. A male client with Herpes Zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the etiology of this problem?

Correct answer: A

Rationale: The correct answer is A: Pain. The pain caused by Herpes Zoster (shingles) can disrupt sleep patterns. It is a common symptom of shingles and can lead to difficulty falling asleep or staying asleep. Nocturia (B), dyspnea (C), and frequent cough (D) are not typically associated with shingles and would not directly cause difficulty sleeping in this scenario.

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