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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.
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The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
- A. Delayed afferent nerve impulses
- B. Delayed efferent nerve impulses
- C. Desynthesis in upper extremities
- D. Slows nerve impulse transmission
Correct Answer: D
Rationale: Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
- A. Giving antibiotics prior to treatments
- B. Monitoring the client's vital signs
- C. Performing appropriate hand hygiene
- D. Placing the client in protective isolation
Correct Answer: C
Rationale: Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
- A. Ask the client to explain his feelings related to this disorder
- B. Ask how dental hygiene is related to overall health
- C. Tell the client that he will become malnourished in time
- D. Inform the client about dental care options
Correct Answer: A
Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
- A. I can scratch with a coat hanger
- B. I should feel my fingers for warmth
- C. I will keep the cast clean and dry
- D. I will return to have the cast removed
Correct Answer: A
Rationale: Nothing should be placed under the cast to use for scratching, as this can cause skin damage or infection. The other statements show a good understanding of cast care instructions.
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
- A. Avoid others who are ill
- B. Check blood sugars four times a day
- C. Use two forms of contraception
- D. Wear properly fitting socks and shoes
Correct Answer: A
Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. While it is important to avoid injury, this is not specific to corticosteroid use.