A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine? A. Ulcerative colitis B. Blood dyscrasia C. Intestinal obstruction D. Spinal cord injury … Read More »
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet.… Read More »
A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? A. Urine output increases. B. Pupils are 8 mm and nonreactive. C. Systolic blood pressure remains at 150 mm Hg. D. BUN and creatinine levels return… Read More »
A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note: A. Vertigo, tinnitus, and hearing loss. B. Vertigo, vomiting, and nystagmus. C. Vertigo, pain, and hearing impairment. D. Vertigo, blurred vision, and fever.… Read More »
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together. Correct Answer: B. To immobilize… Read More »
Which of the following values is considered normal for ICP? A. 0 to 15 mm Hg B. 25 mm Hg C. 35 to 45 mm Hg D. 120/80 mm Hg Correct Answer: A. 0 to 15 mm Hg Normal ICP is 0-15 mm Hg. Intracranial hypertension (IH)… Read More »
A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction? A. “Lie in bed with your head elevated, and refrain from… Read More »
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede’s maneuver… Read More »
Which of the following symptoms may occur with a phenytoin level of 32 mg/dl? A. Ataxia and confusion B. Sodium depletion C. Tonic-clonic seizure D. Urinary incontinence Correct Answer: A. Ataxia and confusion A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl… Read More »
Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common? A. Excessive tearing B. Urine retention C. Muscle weakness D. Slurred speech Correct Answer: C. Muscle weakness The most common adverse reaction to dantrolene is muscle weakness. The drug also may… Read More »