Nokea
The initial neurological symptom of Guilain-Barre Syndrome is:
- A. Absent tendon reflex
- B. Paresthesia of the legs
- C. Dysrhythmias
- D. Transient hypertension Toni a 32 year old mother of two has had multiple sclerosis for 5 years. She is currently enrolled in a school of nursing. Her husband is supportive and helps with care of their preschool sons. Toni has been admitted to the clinical area for diagnostic studies related to symptoms of visual disturbances.
Correct Answer: B
Rationale: Step 1: Guillain-Barre Syndrome (GBS) is characterized by a rapid onset of weakness and tingling sensations in the legs.
Step 2: Paresthesia refers to abnormal sensations like tingling or numbness, which is a common initial neurological symptom of GBS.
Step 3: Absent tendon reflexes may occur in GBS due to muscle weakness but are not typically the initial symptom.
Step 4: Dysrhythmias and transient hypertension are not typical symptoms of GBS and are not associated with its initial presentation.
In summary, choice B is correct as paresthesia of the legs is a hallmark initial neurological symptom of Guillain-Barre Syndrome, while choices A, C, and D are incorrect as they do not align with the typical presentation of GBS.
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The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?
- A. The patient states that he will be careful to avoid injury.
- B. The patient can list signs and symptoms of bleeding.
- C. The patient uses an electric razor instead of his safety razor.
- D. The patient states when he should call the doctor.
Correct Answer: C
Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
- A. Complete
- B. Focused
- C. General
- D. Time-lapse
Correct Answer: B
Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge.
A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation.
C: General assessments are broad and not targeted towards a specific issue like infection at an incision site.
D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection.
In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.
When teaching a client about insulin administration, the nurse should include which instruction?
- A. “Administer insulin after the first meal of the day.”
- B. “Inject insulin at a 45-degree angle into the deltoid muscle.”
- C. “Shake the insulin vial vigorously before withdrawing the medication.”
- D. “Draw up clear insulin first when mixing two types of insulin in one syringe.”
Correct Answer: D
Rationale: The correct answer is D because drawing up clear insulin first when mixing two types of insulin in one syringe prevents contamination. Clear insulin is drawn up first to avoid clouding from the cloudy insulin. This ensures accurate dosing and prevents potential medication errors.
A: Incorrect. Administering insulin after the first meal may lead to hypoglycemia if the client skips or delays meals.
B: Incorrect. Insulin should not be injected into the deltoid muscle as it can lead to inconsistent absorption rates.
C: Incorrect. Vigorously shaking the insulin vial can cause bubbles, affecting the accuracy of the dose and potentially altering its effectiveness.
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
- A. Consider cultural differences during this assessment.
- B. Ask the patient to make eye contact to determine her affect.
- C. Continue with the interview and document that the patient is depressed.
- D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A
Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.
A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
- A. Sinusitis
- B. Lymphadenopathy
- C. Anaphylaxis
- D. Angioedema
Correct Answer: A
Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications.
Summary of other choices:
B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis.
C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis.
D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.