A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

"I've been having problems with bladder control."

"I have difficulty swallowing food."

"I have a hard time with brushing my hair."

"I would rather be in a wheelchair than use a walker to get around."

Answer and Explanation

The Correct Answer is C

Choice A reason: While bladder control issues can significantly affect a client's quality of life, they are typically managed by a urologist or a specialist in continence, rather than an occupational therapist. Occupational therapy focuses on improving the ability to perform activities of daily living (ADLs), which generally does not include bladder control.

Choice B reason: Difficulty swallowing, known as dysphagia, can be a symptom of myasthenia gravis due to muscle weakness. Although it is a serious concern, it is usually managed with the help of a speech therapist who specializes in swallowing difficulties, rather than an occupational therapist.

Choice C reason: Having a hard time with brushing hair is directly related to the performance of ADLs, which is the primary focus of occupational therapy. An occupational therapist can assist the client by teaching energy conservation techniques, providing adaptive equipment, and modifying the task to make it easier for the client to maintain personal grooming independently.

Choice D reason: Preferring a wheelchair over a walker is a matter of mobility and personal preference. While occupational therapy can help with mobility issues, this statement alone does not indicate a need for occupational therapy unless the client has difficulty performing ADLs due to the choice of mobility aid.

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Correct Answer is D

Explanation

Choice A reason: Taking two tablets PO every 15 minutes is not the standard protocol for nitroglycerin administration for chest pain. This method could lead to an overdose and significant hypotension (low blood pressure), which can be dangerous.

Choice B reason: One tablet SL every 15 minutes, up to 5 times, is also not the standard protocol. While sublingual administration is correct, the frequency and the total number of doses are higher than recommended, which could result in adverse effects such as headache, dizziness, or a severe drop in blood pressure.

Choice C reason: One tablet PO every one hour, up to 5 times, is not a recommended method for acute chest pain relief from angina. Oral administration does not provide the rapid onset of action required for acute angina relief.

Choice D reason: One tablet SL every 5 minutes, up to 3 times, is the correct protocol for nitroglycerin administration when experiencing chest pain due to angina. If pain persists after the first dose, the patient can take a second dose after 5 minutes, and if needed, a third dose after another 5 minutes. If chest pain continues after three doses in 15 minutes, emergency medical help should be sought immediately.

A. Epinephrine B. Furosemide C. Nitroprusside D. Desmopressin

Correct Answer is D

Explanation

Choice A reason: Epinephrine is primarily used in emergency situations for its vasoconstrictive and bronchodilatory effects, particularly in cases of anaphylaxis or cardiac arrest. It is not typically used to manage symptoms associated with brainstem contusions or to regulate urinary output.

Choice B reason: Furosemide is a loop diuretic commonly prescribed to reduce fluid retention in conditions such as heart failure or renal disease. Given that the client has already produced a large volume of urine (4,000 mL in 24 hours, which is above the normal range of 800 to 2,000 milliliters per day), administering furosemide would not be appropriate as it would likely exacerbate the excessive urinary output.

Choice C reason: Nitroprusside is a potent vasodilator used to treat acute hypertensive crises. It has no role in the management of thirst or regulation of urinary output and is not indicated for the treatment of brainstem contusions.

Choice D reason: Desmopressin is a synthetic analogue of the naturally occurring antidiuretic hormone vasopressin. It is used to treat conditions characterized by excessive urination, such as diabetes insipidus, and to manage polyuria and polydipsia (excessive thirst) following head trauma or surgery in the pituitary region. In the context of a brainstem contusion with a reported high urinary output, desmopressin would be the appropriate medication to prescribe to reduce urine volume and address the client's thirst.

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A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain:

Correct Answer is D

Explanation

A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications?

Correct Answer is D

Explanation

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