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The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit, she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement?
- A. Tell the wife she must stop crying.
- B. Escort the wife out of the room.
- C. Medicate the client immediately.
- D. Acknowledge the wife's fears.
Correct Answer: D
Rationale: Acknowledging the wife’s fears provides emotional support, potentially calming both her and the client. Ordering her to stop, escorting her out, or medicating the client are less therapeutic.
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Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome?
- A. Assess deep tendon reflexes.
- B. Complete a Glasgow Coma Scale.
- C. Check for Babinski's reflex.
- D. Take the client's vital signs.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a hallmark of Guillain-Barré syndrome due to peripheral nerve involvement. Glasgow Coma Scale, Babinski’s reflex, and vital signs are less specific.
The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?
- A. Provide an erase slate board for the client to write on.
- B. Instruct the client to blink once for 'no' and twice for 'yes.'
- C. Refer to a speech therapist to help with communication.
- D. Leave the call light within easy reach of the client.
Correct Answer: B
Rationale: Blinking (once for no, twice for yes) is a simple communication method for a ventilated client with paralysis. Writing, speech therapy, and call light access are less feasible.
The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client?
- A. The client will maintain reproductive ability.
- B. The client will verbalize feelings of body-image changes.
- C. The client will have no deterioration of organ function.
- D. The client’s skin will remain intact and have no irritation.
Correct Answer: C
Rationale: Preventing organ deterioration is critical in SLE to avoid life-threatening complications. Reproduction, body image, and skin integrity are secondary.
The nurse on a medical floor is caring for clients diagnosed with AIDS. Which client should be seen first?
- A. The client who has flushed, warm skin with tented turgor.
- B. The client who states the staff ignores the call light.
- C. The client whose vital signs are T 99.9°F, P 101, R 26, and BP 110/68.
- D. The client who is unable to provide a sputum specimen.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea suggest infection or sepsis, requiring immediate assessment. Dehydration, call light complaints, and sputum issues are less acute.
The female client is homeless and pregnant. The client supports an IV drug habit by prostitution. Which data would be considered antecedents (risk factor) for becoming HIV positive? Select all that apply.
- A. The client is pregnant.
- B. The client is an intravenous drug abuser.
- C. The client has multiple sexual partners.
- D. The client does not have available health care.
- E. The client does not have adequate bathroom facilities.
- F. The client spends her money on nonessential items.
Correct Answer: B,C,D
Rationale: IV drug use, multiple sexual partners, and lack of healthcare increase HIV risk. Pregnancy, bathroom facilities, and spending are not direct risk factors.