Nokea
The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?
- A. Provide an erase slate board for the client to write on.
- B. Instruct the client to blink once for 'no' and twice for 'yes.'
- C. Refer to a speech therapist to help with communication.
- D. Leave the call light within easy reach of the client.
Correct Answer: B
Rationale: Blinking (once for no, twice for yes) is a simple communication method for a ventilated client with paralysis. Writing, speech therapy, and call light access are less feasible.
You may also like to solve these questions
The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Take with an over-the-counter medication for the stomach.
- B. Drink a full glass of water with each pill.
- C. If a dose is missed, double the medication at the next dosing time.
- D. Avoid taking the NSAID on an empty stomach.
Correct Answer: D
Rationale: Taking NSAIDs with food prevents gastric irritation. OTC stomach meds are not routine, water volume is secondary, and doubling doses is dangerous.
The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention?
- A. The client complains of joint stiffness and the knees feel warm to the touch.
- B. The client has experienced one (1)-kg weight loss and is very tired.
- C. The client requires a heating pad applied to the hips and back to sleep.
- D. The client is crying, has a flat facial affect, and refuses to speak to the nurse.
Correct Answer: D
Rationale: Crying, flat affect, and refusal to speak suggest depression or suicidal ideation, requiring immediate intervention. Stiffness, weight loss, and heating pad use are expected in RA.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement?
- A. Tell the wife she must stop crying.
- B. Escort the wife out of the room.
- C. Medicate the client immediately.
- D. Acknowledge the wife's fears.
Correct Answer: D
Rationale: Acknowledging the wife’s fears provides emotional support, potentially calming both her and the client. Ordering her to stop, escorting her out, or medicating the client are less therapeutic.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse?
- A. The client is able to mark the correct site for the surgery.
- B. The client can only tell the nurse about the surgery in lay terms.
- C. The client is allergic to iodine and does not have an allergy bracelet.
- D. The client has signed a consent form for surgery and anesthesia.
Correct Answer: C
Rationale: Missing an allergy bracelet for iodine risks exposure during surgery, requiring immediate intervention. Site marking, lay terms, and consent are appropriate.