Nokea
Because a client has Guillain-Barré syndrome, the nurse would expect which of the following in the client's history?
- A. Recent upper respiratory infection
- B. A tick bite a few days ago
- C. A mosquito bite a week ago
- D. A strep throat infection two weeks ago
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral upper respiratory infection, triggering an autoimmune response, unlike tick bites, mosquito bites, or strep throat.
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The nurse who is the primary caregiver for an adult client receives a telephone report from the Microbiology Department that the client's blood culture is positive for gram-negative rods. The client is not on antibiotics. What should the nurse do first?
- A. Document the result in the appropriate area of the chart
- B. Inform the client that the nurse now knows what is causing his illness
- C. Place a call to the physician and document the results of the lab work and the notification of the physician in the nurse's notes
- D. Place the laboratory report on the client's chart as soon as possible
Correct Answer: C
Rationale: Notifying the physician promptly ensures timely antibiotic initiation for a positive blood culture, the priority action.
The nurse is making a home visit for a client with an abdominal wound.
When irrigating the draining wound with a sterile saline solution, which of the following sequences would be MOST appropriate for the nurse to follow?
- A. Pour the solution, wash hands, and remove the soiled dressing.
- B. Wash hands, prepare the sterile field, and remove the soiled dressing.
- C. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing.
- D. Remove the soiled dressing, flush the wound, and wash hands.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) hands should be washed first (2) correct-handwashing should be done prior to beginning any procedure, especially irrigating a wound (3) using sterile gloves to remove the dressing would contaminate them (4) hands should be washed first
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?
- A. Wine, beer, cheese, liver and chocolate
- B. Wine, citrus fruits, yogurt and broccoli
- C. Beer, cheese, beef and carrots
- D. Wine, apples, sour cream and beef steak
Correct Answer: A
Rationale: These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following client statements would be of GREATest concern to the nurse?
- A. I use my inhaler four times a day.
- B. I have a dry mouth.
- C. I feel dizzy sometimes.
- D. I rinse my mouth after using the inhaler.
Correct Answer: C
Rationale: Dizziness may indicate systemic absorption or hypoxia, a serious concern in COPD requiring evaluation. Options A, B, and D are less concerning: four times daily is standard, dry mouth is a common side effect, and rinsing is appropriate.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.