Page 2059 - Saunders Comprehensive Review For NCLEX-RN

indications that a client who has had a stroke is adapting most successfully. Options
1 and 2 are behaviors that may be expected in the client with a stroke, but they are
not adaptive responses. Instead, they are a result of the insult to the brain. Options 3
and 4 indicate that the client is trying to adapt, but the correct option has the best
outcome.
Level of Cognitive Ability: Evaluating
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Stroke
Priority Concepts: Coping; Functional Ability
Reference: Ignatavicius, Workman, Rebar (2018), pp. 939-940.

714. Answer: 1

Rationale: Clients with myasthenia gravis are taught to space out activities over
the day to conserve energy and restore muscle strength. Taking medications
correctly to maintain blood levels that are not too low or too high is important.
Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating
is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep
habits, and emotional stress.
Test-Taking Strategy: Note the strategic words, most effective. Recalling that the
common causes of myasthenic and cholinergic crises are undermedication and
overmedication, respectively, will assist you in eliminating each of the incorrect
options. No other option would prevent both of those complications.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Myasthenia gravis
Priority Concepts: Client Education; Safety
Reference: Ignatavicius, Workman, Rebar (2018), pp. 920, 922.

715. Answer: 4

Rationale: The client with Parkinson’s disease should be instructed regarding
safety measures in the home. The client should use her or his walker as support to
get to the bathroom because of bradykinesia. The client should sit down to put on
pants and shoes to prevent falling. The client should exercise every day in the
morning when energy levels are highest. The client should have all loose rugs in the
home removed to prevent falling.
Test-Taking Strategy: Note the strategic words, need for further teaching. These
words indicate a negative event query and the need to select the incorrect client
statement as the answer. Recall that clients with Parkinson’s disease are at risk for
falls.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity

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