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. Cancer cells typically lose their specialized functions and characteristics that normal cells have. This loss of differentiation is known as dedifferentiation, where cancer cells become less specialized and more primitive in nature. This allows them to proliferate rapidly and invade surrounding tissues.
B. Contact inhibition refers to the normal process where cells stop dividing when they come into contact with neighboring cells. In cancer cells, this mechanism is disrupted, leading to uncontrolled cell growth and proliferation. Cancer cells continue to divide and grow even when they are in close contact with other cells, which contributes to tumor formation and progression.
C. Cancer cells often acquire mutations that impair their ability to repair DNA damage effectively. This can lead to an accumulation of genetic mutations over time, which is a hallmark of cancer development. While some cancer cells may still have mechanisms to repair DNA damage, they are often less efficient compared to normal cells, leading to genomic instability and further mutation accumulation.
D. Normal cells follow a tightly regulated cell cycle with specific checkpoints that ensure orderly progression through phases such as G1, S, G2, and M phases. In contrast, cancer cells often have dysregulated cell cycle control. They may bypass checkpoints that normally control cell division, leading to uncontrolled proliferation and growth.
Correct Answer is A
Explanation
A. Retropulsion is a classic manifestation of postural instability in Parkinson's disease. It refers to a tendency to lose balance and fall backward, especially when attempting to initiate walking or when challenged with external forces.
B. Impaired handwriting, also known as micrographia, is associated with bradykinesia (slowness of movement) in Parkinson's disease. It manifests as progressively smaller and more cramped handwriting.
C. Muscle soreness and pain can occur in Parkinson's disease, but they are not typically directly associated with postural instability. They may occur due to rigidity (muscle stiffness) or abnormal postures maintained over time.
D. Slow movements, or bradykinesia, are a hallmark feature of Parkinson's disease and are characterized by a gradual reduction in the speed and fluidity of voluntary movements. While related to motor symptoms in Parkinson's disease, slow movements are not specific to postural instability.
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