Nokea
A client with Guillain-Barr© syndrome is experiencing ascending paralysis. Which of the following interventions should the nurse prioritize?
- A. Monitor for signs of respiratory distress.
- B. Prepare the client for plasmapheresis.
- C. Administer analgesics for pain management.
- D. Initiate passive range-of-motion exercises.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of respiratory distress. In Guillain-Barr© syndrome, ascending paralysis can lead to respiratory muscle involvement, putting the client at risk for respiratory distress and failure. Prioritizing respiratory monitoring is crucial to ensure timely intervention if respiratory compromise occurs. Plasmapheresis (Choice B) may be indicated in some cases to remove harmful antibodies, but the priority in this situation is respiratory support. Administering analgesics (Choice C) for pain management and initiating passive range-of-motion exercises (Choice D) are important aspects of care but are not the priority when the client's respiratory status is at risk.
You may also like to solve these questions
After studying about viruses, which information indicates the student has a good understanding of viruses? Viruses:
- A. Contain no RNA or DNA
- B. Are capable of independent reproduction
- C. Replicate their genetic material inside host cells
- D. Are killed easily by antimicrobials
Correct Answer: C
Rationale: The correct answer is C. Viruses replicate their genetic material inside host cells, which is a fundamental aspect of their life cycle. Choice A is incorrect because viruses contain either RNA or DNA. Choice B is incorrect as viruses cannot reproduce independently and rely on host cells for replication. Choice D is incorrect as viruses are not easily killed by antimicrobials due to their unique structure and mechanisms of infection.
Which statement best conveys an aspect of the role of cerebrospinal fluid (CSF)?
- A. CSF provides immune protection to the brain and spinal cord by serving as a physical barrier.
- B. CSF cushions the brain and spinal cord, protecting them from injury.
- C. CSF plays a limited role in the exchange of nutrients and waste products between the blood and brain.
- D. CSF functions primarily as a medium for the transmission of nerve impulses.
Correct Answer: B
Rationale: The correct answer is B. Cerebrospinal fluid primarily cushions the brain and spinal cord, protecting them from injury. Choice A is incorrect because while CSF contributes to the brain's immune environment, its main role is not providing immune protection as a physical barrier. Choice C is incorrect because CSF has a significant role in the exchange of nutrients and waste products, rather than a limited one. Choice D is incorrect as CSF is not primarily a medium for nerve impulse transmission, but rather serves as a protective and supportive fluid.
A 69-year-old female patient has been diagnosed with malignant melanoma. The care team has collaborated with the patient and her family and agreed on a plan of care that includes administration of interferon alfa-2b. After administering interferon alfa-2b, the oncology nurse should anticipate that the patient may develop which of the following adverse effects?
- A. Profound diaphoresis
- B. Decreased level of consciousness
- C. Flu-like symptoms
- D. Cyanosis and pallor
Correct Answer: C
Rationale: After the administration of interferon alfa-2b, the patient may develop flu-like symptoms as an adverse effect. Flu-like symptoms are commonly associated with interferon therapy, including fever, chills, fatigue, and muscle aches. These symptoms usually subside over time. Options A, B, and D are not typically associated with interferon alfa-2b administration. Profound diaphoresis is excessive sweating, decreased level of consciousness indicates neurological issues, and cyanosis and pallor suggest circulatory or respiratory problems, none of which are expected adverse effects of interferon alfa-2b.
A female patient is concerned about the side effects of oral contraceptives. What should the nurse explain as a common side effect?
- A. Increased energy levels
- B. Decreased libido
- C. Weight gain
- D. Hair loss
Correct Answer: C
Rationale: The correct answer is C: Weight gain. Weight gain is a common side effect of oral contraceptives due to hormonal changes. It is essential for healthcare providers to inform patients about this possibility to manage expectations.
Choice A, increased energy levels, is not a common side effect of oral contraceptives.
Choice B, decreased libido, can be a side effect for some individuals but is not as common as weight gain.
Choice D, hair loss, is not typically associated with oral contraceptives. Therefore, it is important for the nurse to address the patient's concerns by discussing the more prevalent side effects like weight gain.
How often should a patient be administered a tetanus toxoid?
- A. Every year
- B. Every 10 years
- C. Every 2 years
- D. Every 5 years
Correct Answer: B
Rationale: Tetanus toxoid should be administered every 10 years to ensure continued protection against tetanus infection. The correct answer is 'Every 10 years.' Choice A ('Every year') is incorrect as the frequency is too frequent. Choice C ('Every 2 years') is incorrect as it is too frequent for tetanus toxoid administration. Choice D ('Every 5 years') is incorrect as it does not align with the recommended interval for tetanus toxoid booster doses.