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A nurse is assessing a client who has Guillain-Barr© syndrome. Which of the following findings should the nurse expect?
- A. Increased urine output.
- B. Hyperactive reflexes.
- C. Hypoactive bowel sounds.
- D. Facial weakness.
Correct Answer: D
Rationale: Facial weakness is a common finding in clients with Guillain-Barr© syndrome due to muscle weakness. While increased urine output is not typically associated with Guillain-Barr© syndrome, hyperactive reflexes are more indicative of conditions like hyperthyroidism or spinal cord injury. Hypoactive bowel sounds are not a classic finding in Guillain-Barr© syndrome, making it an incorrect choice.
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A nurse is caring for a client who has experienced a stroke and has aphasia. Which of the following communication strategies should the nurse use?
- A. Speak louder to help the client understand
- B. Speak using simple sentences and gestures
- C. Use a picture board to facilitate communication
- D. Have the client practice writing words down
Correct Answer: C
Rationale: The correct answer is to use a picture board to facilitate communication. Aphasia can make it challenging for individuals to understand and use language. Using a picture board can help the client convey their needs and understand information more effectively. Speaking louder (A) may not be helpful as aphasia is not related to hearing loss. While speaking using simple sentences and gestures (B) can be beneficial, using a picture board (C) is a more concrete and visual method to support communication for individuals with aphasia. Having the client practice writing words down (D) may not be suitable if the client's expressive language skills are impaired due to aphasia.
A client has a new prescription for furosemide. Which of the following laboratory values should the nurse monitor?
- A. Potassium
- B. Sodium
- C. Calcium
- D. Hemoglobin
Correct Answer: A
Rationale: When a client is prescribed furosemide, monitoring potassium levels is crucial due to the drug's potential to cause hypokalemia. Furosemide is a loop diuretic that promotes potassium excretion in the urine, leading to a risk of low potassium levels. Monitoring potassium levels helps in detecting and preventing hypokalemia, which can result in adverse effects like cardiac dysrhythmias. Sodium, calcium, and hemoglobin levels are usually not directly affected by furosemide, making them less pertinent for monitoring in this specific scenario.
A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Position the client supine with a pillow between the legs.
- B. Place an abduction pillow between the client's legs.
- C. Place a pillow under the client's knees.
- D. Position the client's legs in adduction.
Correct Answer: B
Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.
A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.
A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report?
- A. A client receives antibiotics 2 hours late.
- B. A client vomits within 20 minutes of taking morning medications.
- C. A client requests a statin to be administered at 2100.
- D. A client asks for pain medication 1 hour early.
Correct Answer: A
Rationale: The correct answer is A. Administering antibiotics late must be reported as it can compromise the effectiveness of the treatment. This delay can lead to subtherapeutic levels of the antibiotic in the client's system, potentially reducing its efficacy in combating the infection. Choice B, a client vomiting shortly after taking medication, should be noted but does not necessarily require an incident report unless it is a frequent occurrence. It could indicate a possible adverse reaction or intolerance to the medication. Choice C, a client requesting a statin at a specific time, and choice D, a client asking for pain medication slightly earlier, do not involve medication errors or deviations that pose immediate risks to the client's health, so they do not require incident reports.