Nokea
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000 mm3, magnesium 0.8 mg/dL, and sodium 138 mEq/L. What action by the nurse is best?
- A. Advise the client to restrict fluids
- B. Assess the client for signs of infection
- C. Have the client add table salt to food
- D. Instruct the client on a magnesium supplement
Correct Answer: D
Rationale: Iron and magnesium deficiencies can exacerbate symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed based on the laboratory results.
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A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
- A. Anxiety
- B. Low fluid volume
- C. Inadequate airway
- D. Potential for skin breakdown
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
- A. Administering anxiolytics
- B. Administering a ventilator
- C. Obtaining atropine sulfate
- D. Sedating the client
Correct Answer: C
Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator may be needed, but emergency equipment should be available.
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching? (Select all that apply.)
- A. Acyclovir (Zovirax)
- B. Carbamazepine (Tegretol)
- C. Famciclovir (Famvir)
- D. Prednisone (Deltasone)
- E. Valacyclovir (Valtrex)
Correct Answer: A,C,D,E
Rationale: Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
- A. Bladder control
- B. Cognitive perception
- C. Respiratory system
- D. Sensory functions
Correct Answer: C
Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
An older client is hospitalized with Guillain-Barr?© syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
- A. Assess the client's oxygen saturation
- B. Check the medication list for interactions
- C. Place the client on a bed alarm
- D. Put the client on safety precautions
Correct Answer: A
Rationale: In an older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate but only after this assessment occurs.