A nurse is assigned to care for a client on a medical-surgical unit.
Based on the information provided, the client is likely experiencing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Myasthenia Gravis
Myasthenia Gravis (MG) is an autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles. Key features include fluctuating muscle weakness that typically worsens with activity and improves with rest, bilateral ptosis (drooping of the eyelids), and difficulty with swallowing and speaking. The fact that the client's facial muscle strength is better in the morning and worsens throughout the day is a hallmark of MG. The edrophonium (Tensilon) test is specifically used to diagnose MG by temporarily improving muscle strength.
Antibodies at the neuromuscular junction
Myasthenia Gravis is caused by the presence of autoantibodies that target acetylcholine receptors at the neuromuscular junction, leading to impaired communication between nerves and muscles. This is consistent with the described symptoms and the use of the edrophonium (Tensilon) test to diagnose the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Casts in the urine are typically associated with kidney problems, such as glomerulonephritis or kidney infections, rather than biliary obstruction. Casts are formed from proteins or cells in the renal tubules and are not related to bile duct obstruction or cholelithiasis.
B. Dark, tarry stools are indicative of upper gastrointestinal bleeding and the presence of digested blood in the stool. This condition, known as melena, is not typically associated with obstruction of the common bile duct due to cholelithiasis.
C. Jaundice is a common and significant finding in cases of obstruction of the common bile duct due to cholelithiasis. When the bile duct is obstructed, bilirubin, which is a component of bile, accumulates in the bloodstream because it cannot be properly excreted into the intestine.
D. Pain from cholelithiasis (gallstones) typically occurs in the right upper quadrant, not the left. The right upper quadrant pain is often associated with gallbladder inflammation or bile duct obstruction.
Correct Answer is ["50"]
Explanation
Flow rate in gtt/min = (Volume in mL * Drop factor) / Time in minutes.
The prescribed volume is 150 mL/hr. Since there are 60 minutes in an hour, the time for one hour would be 60 minutes. The drop factor is 20 gtt/mL.
(150 mL/hr * 20 gtt/mL) / 60 min/hr = 3000 gtt/hr / 60 min/hr = 50 gtt/min.
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
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