Nokea
For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?
- A. Urinary incontinence
- B. Deep vein thrombosis
- C. Hypertension
- D. Hypoglycemia
Correct Answer: B
Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.
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The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- A. Potential for injury.
- B. Powerlessness.
- C. Disturbed thought processes.
- D. Sexual dysfunction.
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?
Correct Answer: 4 gtts/min
Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.