Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis?
a. Pupil size
b. Grip strength
c. Respiratory effort
d. Level of consciousness
ANS: C
Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.
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1) Parasomnias 2) Dyssomnias 3) Insomnia 4) Hypersomnia
Which does the nurse use to evaluate muscle strength?
1. Measures muscle size 2. Performs range of motion 3. Applies pressure against resistance 4. Observes the client's gait and transfers
If an older adult patient must be physically restrained, who is responsible for the patient's safety?
a. Nurse assigned to care for the patient b. Nursing assistant who applies the restraint c. Health care provider who ordered the application of restraint d. Family member who agrees to the application of the restraint
The nurse suspects a client has received too much phenylephrine (Neo-Synephrine). Which findings support the nurse's suspicion?
A. The client's heart rate has increased from 72 bpm to 114 bpm. B. The client reports feeling anxious. C. The client's blood pressure has increased from 140/86 mmHg to 180/98 mmHg. D. The client's stools are dark and tarry. E. The client reports burning at the injection site.