Nokea
After receiving an annual influenza immunization, a client develops symptoms suggestive of Guillain-Barré syndrome. Which symptom is associated with Guillain-Barré syndrome?
- A. Paresthesia and weakness of the lower extremities
- B. Hyperactive deep tendon reflexes
- C. Emotional lability
- D. Flapping tremors of the hand and feet
Correct Answer: A
Rationale: Guillain-Barré syndrome causes paresthesia and weakness in the lower extremities , progressing upward. Reflexes are hypoactive (B is incorrect). Emotional lability and tremors are not typical.
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The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following instructions should the nurse include?
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after use.
- C. Stop the medication if symptoms improve.
- D. Avoid regular asthma follow-ups.
Correct Answer: B
Rationale: Rinsing the mouth prevents oral thrush, a fluticasone side effect. Options A, C, and D are incorrect.
A 78-year-old client is admitted in heart failure. Which assessment is essential for the nurse to make because the client is in heart failure? Select all that apply.
- A. Check pedal pulses.
- B. Check legs for pitting edema.
- C. Upper extremity neuro checks.
- D. Auscultate lung sounds.
- E. Observe respirations.
- F. Observe for gait disturbances.
Correct Answer: B,D,E
Rationale: Persons who are in heart failure are at risk for developing pulmonary edema. The nurse should listen for lung sounds, check legs for pitting edema, which is common in heart failure, and observe respirations for severe dyspnea. Pedal pulses, upper extremity neuro checks, and gait disturbances are not related to heart failure or to pulmonary edema.
A client with pneumonia.
Which of the following nursing observations would indicate a therapeutic response to the treatment?
- A. Oral temperature of 101°F (38.3°C), increased chest pain with nonproductive cough.
- B. Cough, productive of thick green sputum, client reports feeling tired.
- C. Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum.
- D. White cell count of 10,000 mm³, urine output at 40 cc per hour, decreasing amount of sputum.
Correct Answer: C
Rationale: Strategy: Determine which answer choice indicates an improved respiratory status. (1) validates the continued presence of the infection (2) validates the continued presence of the infection (3) correct-sputum characteristics indicate a decrease in the pneumonia; is supported by respiratory status (4) does not substantiate the status of the infection
A client has undergone a lumbar puncture for examination of the CSF. Which of the following findings should be considered abnormal?
- A. Total protein $40 \mathrm{mg} / 100 \mathrm{~mL}$
- B. Glucose $60 \mathrm{mg} / 100 \mathrm{~mL}$
- C. Clear, colorless appearance
- D. White blood cells $100 / \mathrm{cu}$. $\mathrm{mm}$
Correct Answer: D
Rationale: Elevated white blood cells (100/cu.mm) in CSF suggest infection or inflammation, an abnormal finding. Normal protein, glucose, and clear appearance are expected.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.