Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
A. Confusion
Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output
Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure
Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness
Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.
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Full Explanation
A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.
Similar Questions
A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?
A. Cardiac rhythm
Monitoring cardiac rhythm is not specifically necessary for ethambutol therapy.
B. Urine output
Urine output is not a primary concern related to ethambutol use.
C. Visual acuity
Visual acuity should be monitored because ethambutol can cause optic neuritis, which may lead to vision changes and requires regular assessment.
D. Skin color
Skin color is not a specific concern with ethambutol therapy; monitoring for visual changes is more pertinent.
Full Explanation
A. Monitoring cardiac rhythm is not specifically necessary for ethambutol therapy.
B. Urine output is not a primary concern related to ethambutol use.
C. Visual acuity should be monitored because ethambutol can cause optic neuritis, which may lead to vision changes and requires regular assessment.
D. Skin color is not a specific concern with ethambutol therapy; monitoring for visual changes is more pertinent.
A nurse is instructing a group of clients about nutrition and eating foods high in iron. The nurse should include that which of the following aids in the absorption of iron?
A. Vitamin C
Vitamin C enhances the absorption of non-heme iron from plant-based sources by converting iron to a more absorbable form. Including vitamin C-rich foods with iron-rich meals can improve iron uptake.
B. Oxalates
Oxalates, found in foods like spinach and rhubarb, can inhibit iron absorption by binding to iron and reducing its availability.
C. Fiber
Fiber, while beneficial for digestive health, does not enhance iron absorption and can, in some cases, inhibit it by binding to minerals.
D. Vitamin A
Vitamin A does not have a direct role in the absorption of iron, though it is essential for overall health.
Full Explanation
A. Vitamin C enhances the absorption of non-heme iron from plant-based sources by converting iron to a more absorbable form. Including vitamin C-rich foods with iron-rich meals can improve iron uptake.
B. Oxalates, found in foods like spinach and rhubarb, can inhibit iron absorption by binding to iron and reducing its availability.
C. Fiber, while beneficial for digestive health, does not enhance iron absorption and can, in some cases, inhibit it by binding to minerals.
D. Vitamin A does not have a direct role in the absorption of iron, though it is essential for overall health.
nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
A. "Please ring for assistance when you wish to get out of bed."
Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. "We will have to get a prescription from your provider."
A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. "Yes, you are free to move around as you wish."
Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. "No, you are on strict bedrest and must not be up."
Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.
Full Explanation
A. Clients with Ménière's disease may experience dizziness and balance issues, so it is important to ensure safety by asking them to ring for assistance when moving around to prevent falls or injuries.
B. A prescription from the provider is not typically required for ambulation; instead, safety measures should be in place.
C. Allowing free movement without assistance may increase the risk of falls due to balance problems associated with Ménière's disease.
D. Strict bedrest is generally not necessary unless specifically indicated by the provider; assistance and safety measures are more appropriate.