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 nurse is preparing to administer morning medications. Which medication should the nurse administer first?
- A. The pain medication to a client diagnosed with RA.
- B. The diuretic medication to a client diagnosed with SLE.
- C. The steroid to a client diagnosed with polymyositis.
- D. The appetite stimulant to a client diagnosed with OA.
Correct Answer: C
Rationale: Steroids for polymyositis address inflammation and muscle weakness, a priority in autoimmune disease. Pain, diuresis, and appetite are less urgent.
The client comes to the emergency department complaining of dyspnea and wheezing after eating at a seafood restaurant. The client cannot speak and has a bluish color around the mouth. Which intervention should the nurse implement first?
- A. Initiate an IV with normal saline.
- B. Prepare to intubate the client.
- C. Administer oxygen at 100%.
- D. Ask the client about an iodine allergy.
Correct Answer: C
Rationale: Administering 100% oxygen addresses immediate hypoxia in anaphylaxis, per ABCs. IV fluids, intubation, and allergy history follow.
The client on a medical floor is diagnosed with HIV encephalopathy. Which client problem is priority?
- A. Altered nutrition, less than body requirements.
- B. Anticipatory grieving.
- C. Knowledge deficit, procedures and prognosis.
- D. Risk for injury.
Correct Answer: D
Rationale: HIV encephalopathy increases confusion and motor deficits, making risk for injury the priority. Nutrition, grieving, and knowledge are secondary.
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.
Which client problem is priority for a client diagnosed with RA?
- A. Activity intolerance.
- B. Fluid and electrolyte imbalance.
- C. Alteration in comfort.
- D. Excessive nutritional intake.
Correct Answer: C
Rationale: Chronic pain (alteration in comfort) is a hallmark of RA, impacting quality of life. Activity intolerance, fluid balance, and nutrition are secondary.