Nursing Elites

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?

• A. Diplopia (double vision)
• B. Difficulty swallowing
• C. Weakness in the legs
• D. Fatigue

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. A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?

• A. Restrain the child in the tent and notify the health care provider.
• B. Increase the oxygen concentration in the tent.
• C. Take the child out of the tent and into the playroom.
• D. Ask the mother for help in comforting the child.

Correct answer: B

Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.

3. When selecting patient problems for the 4-year-old child with nephrosis, what should be a priority for the nurse?

• A. Impaired body image
• B. Skin impairment
• C. Nutritional deficit
• D. Injury

Correct answer: B

Rationale: The correct answer is B: Skin impairment. Nephrosis is characterized by gross edema, making skin care a priority. Skin impairment can result from the edema and needs close monitoring and management. While nutritional deficit and injury are important considerations in patient care, they are not the priority when dealing with a child with nephrosis. Impaired body image is not typically a priority in the immediate care of a young child with nephrosis.

4. A client with a spinal cord injury at the level of T1 is at risk for autonomic dysreflexia. Which symptom is indicative of this condition?

• A. Hypotension
• B. Tachycardia
• C. Severe headache
• D. Flushed skin below the level of injury

Correct answer: C

Rationale: Corrected Rationale: Autonomic dysreflexia is a condition commonly seen in clients with spinal cord injuries at T6 or above. It is characterized by a sudden onset of severe hypertension, pounding headache, profuse sweating, nasal congestion, and flushing of the skin above the level of injury. The severe headache is a key symptom resulting from uncontrolled hypertension. Choices A, B, and D are incorrect as autonomic dysreflexia typically presents with hypertension, not hypotension, tachycardia, or flushed skin below the level of injury.

5. Based on this strip, what is the correct interpretation of this rhythm?

• A. Atrial fibrillation.
• B. Premature atrial fibrillation.
• C. AV block.
• D. Ventricular tachycardia.

Correct answer: A

Rationale: The correct interpretation of the rhythm strip is atrial fibrillation. This arrhythmia is characterized by an irregular heartbeat and the absence of distinct P waves. Choice B, premature atrial fibrillation, is incorrect as there is no indication of premature beats in the strip. Choice C, AV block, is also incorrect as there is no evidence of conduction delays between the atria and ventricles. Choice D, ventricular tachycardia, is not supported by the absence of wide QRS complexes typically seen in this arrhythmia.

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