A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?
A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium (Tensilon) test.
A client with Bell's palsy who has an order for prednisone and acyclovir.
A client with Parkinson's disease who has hypokinetic dysarthria and a lack of facial expressions.
A client with multiple sclerosis who has bladder flaccidity and is retaining urine.
The Correct Answer is A
A. A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium test is likely experiencing a myasthenic crisis, which is a life-threatening condition that requires immediate attention. This client would be the priority because they may require rapid intervention to maintain airway and breathing.
B. Bell's palsy is characterized by sudden onset of facial paralysis due to inflammation of the facial nerve. While Bell's palsy can be distressing for the client, it does not typically require urgent intervention unless there are complications such as corneal abrasion due to inability to close the eye.
C. Parkinson's disease is a chronic neurodegenerative disorder characterized by motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. While this client requires ongoing assessment and care, the symptoms described do not typically indicate an acute or urgent need for intervention.
D. A client with multiple sclerosis who has bladder flaccidity and is retaining urine needs assessment and intervention to prevent complications such as urinary tract infections or renal damage. However, this is not as immediately life-threatening as a myasthenic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Splenectomy is not a standard treatment for myasthenia gravis. The spleen's role is primarily related to immune function and blood filtration rather than the pathophysiology of MG.
B. Thymectomy is a surgical procedure that involves the removal of the thymus gland. The thymus gland plays a role in the development and regulation of the immune system. In some cases of myasthenia gravis, especially in younger patients or those with thymoma (a tumor of the thymus gland), thymectomy can lead to improvement or remission of symptoms. This procedure is considered in cases where myasthenia gravis is refractory to medication or in cases associated with thymoma.
C. Appendectomy is the surgical removal of the appendix and is not a treatment for myasthenia gravis. The appendix is not implicated in the pathophysiology of MG.
D. Cholecystectomy is the surgical removal of the gallbladder and is performed for conditions related to the gallbladder, such as gallstones or inflammation. It is not indicated for the treatment of myasthenia gravis.
Correct Answer is B
Explanation
A. Atrial flutter typically presents with a regular atrial rate (usually around 250-350 beats per minute) and a characteristic "sawtooth" pattern of flutter waves (F-waves) on the ECG. This condition would not present with irregular ventricular rates and is less likely based on the ECG findings described.
B. Atrial fibrillation is identified by an irregularly irregular rhythm and the absence of P-waves on the ECG, which is replaced by erratic activity.
C. Unstable angina presents with chest pain or discomfort due to reduced blood flow to the heart muscles, usually related to atherosclerotic plaque rupture or erosion. It does not cause the ECG findings described (absence of P-waves and irregular ventricular rate).
D. PACs are early atrial depolarizations that can cause palpitations but do not typically result in the absence of P-waves or irregular ventricular rates as described in the scenario.
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