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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Defibrillation is used to treat life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia, where the heart is in a chaotic rhythm without an effective contraction.
B. This procedure is performed to relieve significant blockages in coronary arteries that are causing myocardial ischemia or infarction. While coronary artery disease can contribute to cardiac issues, it is not the primary intervention for treating atrial fibrillation with a rapid ventricular response and associated symptoms like dizziness, shortness of breath, and hypotension.
C. While an echocardiogram may be useful in assessing the overall cardiac function and structure, it is not an immediate intervention for the acute management of atrial fibrillation with a rapid ventricular response and unstable symptoms.
D. Synchronized cardioversion is a procedure used to convert certain types of rapid arrhythmias, including atrial fibrillation, to a normal sinus rhythm by delivering a synchronized electrical shock to the heart at a specific point in the cardiac cycle.
Correct Answer is C
Explanation
A. The soles of the feet are not typically assessed for cyanosis because they are not a reliable indicator of central cyanosis. Cyanosis is best evaluated in areas where mucous membranes are visible.
B. Similar to the soles of the feet, the palms of the hands are not a reliable indicator of central cyanosis. Cyanosis is not typically visible on the palms unless there are severe systemic circulation issues.
C. The oral mucosa (inside the mouth) is a reliable area to assess for central cyanosis. The nurse can inspect the lips, tongue, and buccal mucosa for a bluish discoloration, which indicates decreased arterial oxygen saturation.
D. The nail beds are also a reliable indicator of central cyanosis. The nurse can assess the color of the nail beds and look for bluish discoloration, which can be more apparent in darker-skinned individuals compared to the lips and oral mucosa.
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