The nurse assesses a client who has myasthenia gravis. Which clinical manifestation does the nurse expect to observe in this client?
a. Inability to perform the six cardinal posi-tions of gaze
b. Lateralization to the affected side during the Weber test
c. Absent deep tendon reflexes
d. Impaired stereognosis
A
The most common assessment finding in more than 90% of clients with myasthenia gravis is in-volvement of the extraocular muscles. The nurse observes for inability or difficulty with tests of extraocular function, such as the cardinal positions of gaze. Ptosis and incomplete eye closure also may be observed. Altered hearing and absent reflexes are not common in myasthenia gravis.
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a. "I am glad you are feeling better and have no discomfort." b. "Where do you hurt?" c. "What you are saying and what I am observing don't seem to match." d. "It makes me uncomfortable when you are not honest with me."
A nurse is caring for a 34-year-old patient admitted with severe diarrhea that has been going on for 2 weeks. What assessment should the nurse anticipate?
a. Edema of lower legs and feet b. Hypotension and fatigue c. Hypertension and hunger d. Metabolic alkalosis
The nurse wants to know whether the seven minute screen (7MS) is as accurate as the Mini-Mental State Examination (MMSE) in screening for dementia. Select the correct category for this type of question
a. Prognosis b. Diagnostic c. Harm/etiology d. Prevention
Which of the following would be an appropriate intervention when caring for a client experiencing sensory overload?
a. Provide explanation of all procedures prior to implementation. b. Keep bright lights and the television on in the client's room to help orient her. c. Work as quickly as possible when performing tasks and procedures so the client has more time to rest. d. Encourage as many visitors as possible so the client does not feel lonely.