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?

Confusion

Increased urinary output

Increased intracranial pressure

Weakness

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

A. While pain management may be necessary, it is not the priority in the initial management of a snake bite. The focus should be on addressing the potential spread of venom.

B. Discharging the client is not appropriate as the client requires immediate medical evaluation and treatment due to the venomous snake bite.

C. Removing the elastic bandages is crucial as they can impede blood flow and potentially exacerbate the spread of venom. Elastic bandages should not be used to constrict the limb; proper medical treatment is needed.

D. Obtaining a prescription for anti-venom is important but should be done after initial assessment and treatment of the snake bite. Removing constrictive bandages is the immediate action to take to manage the bite effectively.

A. "These tests help determine the degree of damage to the heart tissues." B. "Cardiac enzymes will identify the location of the MI." C. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion." D. "These tests will enable the provider to determine the heart structure and mobility of the heart valves."

Correct Answer is A

Explanation

A. Cardiac enzyme tests, such as troponin and creatine kinase-MB, are used to assess the extent of myocardial damage. Elevated levels of these enzymes indicate that heart muscle cells have been injured or have died.
B. Cardiac enzymes do not localize the MI; imaging studies like echocardiography or coronary angiography are required to identify the specific location of myocardial damage.
C. Pulmonary congestion is assessed using chest X-rays or clinical symptoms, not through cardiac enzyme levels.
D. Cardiac enzyme tests do not provide information about the structure or mobility of heart valves. This information is obtained through echocardiography or other imaging techniques.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?

Correct Answer is A

Explanation

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