Nokea
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 in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse do next?
- A. Monitor the client's IV site for thrombophlebitis.
- B. Administer flumazenil to the client.
- C. Evaluate the client for further suicidal behavior.
- D. Initiate seizure precautions for the client.
Correct Answer: B
Rationale: Administering flumazenil is the priority to reverse the effects of diazepam overdose. Flumazenil is a specific benzodiazepine receptor antagonist that can rapidly reverse the sedative effects of diazepam. Monitoring the IV site for thrombophlebitis is important but not the immediate priority in this situation. Evaluating the client for further suicidal behavior is important for comprehensive care but is not the most urgent action at this moment. Initiating seizure precautions may be necessary, but the priority is to counteract the sedative effects of diazepam with flumazenil.
A client receiving morphine via patient-controlled analgesia (PCA) should have naloxone administered if their respiratory rate is below 10/min. What action should the nurse take?
- A. Monitor the client's blood pressure every 4 hours.
- B. Ask the client to rate their pain every 2 hours.
- C. Administer naloxone if the client's respiratory rate is below 10/min.
- D. Evaluate the client's use of the PCA every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.
A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?
- A. Tell the client that their delusions are not real
- B. Encourage the client to explore the meaning behind their delusions
- C. Focus on the client's feelings rather than the delusions
- D. Challenge the client's delusions directly
Correct Answer: C
Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?
- A. Position the client supine.
- B. Prepare an IV bolus of dextrose 5% in water.
- C. Administer methylergonovine IM.
- D. Administer calcium gluconate IV.
Correct Answer: D
Rationale: Administering calcium gluconate IV is the correct action when a client displays toxicity from magnesium sulfate. Calcium gluconate is used as the antidote for magnesium sulfate toxicity as it counteracts the effects. Positioning the client supine (Choice A) is not the immediate action needed. Administering dextrose 5% in water (Choice B) is not indicated for magnesium sulfate toxicity. Administering methylergonovine IM (Choice C) is used in postpartum hemorrhage, not for magnesium sulfate toxicity.
A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?
- A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
- B. Keep the infant's head uncovered.
- C. Ensure that the newborn wears a diaper.
- D. Apply lotion to the newborn every 4 hours.
Correct Answer: C
Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.