Nokea
The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement? Select all that apply.
- A. Refer the client to the physical therapist.
- B. Include the speech therapist in the team.
- C. Request a social worker consult.
- D. Implement a regimen to address pain control.
- E. Refer the client to the Guillain-Barré Syndrome Foundation.
Correct Answer: A,C,D,E
Rationale: Physical therapy, social worker consult, pain control, and foundation referral address mobility, psychosocial needs, comfort, and education. Speech therapy is unnecessary without communication issues.
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The client in the HCP's office has a red, raised rash covering the forearms, neck, and face and is experiencing extreme itching which is diagnosed as an allergic reaction to poison ivy. Which discharge instructions should the nurse teach?
- A. Tell the client never to scratch the rash.
- B. Instruct the client in administering IM Benadryl.
- C. Explain how to take a steroid dose pack.
- D. Have the client wear shirts with long sleeves and high necks.
Correct Answer: C
Rationale: A steroid dose pack reduces inflammation and itching in poison ivy reactions. Never scratching is unrealistic, IM Benadryl is HCP-administered, and clothing is preventive.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
- A. Contact Precautions.
- B. Airborne Precautions.
- C. Droplet Precautions.
- D. Standard Precautions.
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
- A. Administer the medication 30 minutes prior to meals.
- B. Instruct the client to take with eight (8) ounces of water.
- C. Explain the importance of sitting up for one (1) hour after taking medication.
- D. Assess the client's blood pressure prior to administering medication.
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
- A. Prepare to administer Solu-Medrol, a glucocorticoid, IV.
- B. Request and obtain a STAT chest x-ray.
- C. Initiate the rapid response team.
- D. Administer epinephrine, an adrenergic blocker, SQ then IV continuous.
- E. Assess the client's pulse and respirations.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.
Which is the highest priority nursing intervention for the client who is having an anaphylactic reaction?
- A. Administer parenteral epinephrine, an adrenergic agonist.
- B. Prepare for immediate endotracheal intubation.
- C. Provide a calm assurance when caring for the client.
- D. Establish and maintain a patent airway.
Correct Answer: D
Rationale: Establishing a patent airway is the highest priority in anaphylaxis, per ABCs. Epinephrine, intubation, and reassurance follow.