Nokea
The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises?
- A. Passive ROM exercises will prevent contractures from developing.
- B. The client will feel better if he is able to exercise and stretch his muscles.
- C. ROM exercises will help alleviate the pain associated with GB syndrome.
- D. They help to prevent DVTs by movement of the blood through the veins.
Correct Answer: D
Rationale: Passive ROM (D) promotes venous return, preventing DVT in immobile GB patients. Contractures (A) are musculoskeletal, feeling better (B) is subjective, and pain relief (C) is not primary.
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Which instruction should the nurse discuss with the client diagnosed with Raynaud's phenomenon?
- A. Explain exacerbations will not occur in the summer.
- B. Use nicotine gum to help quit smoking.
- C. Wear extra-warm clothing during cold exposure.
- D. Avoid prolonged exposure to direct sunlight.
Correct Answer: C
Rationale: Cold triggers Raynaud’s; wearing warm clothing (C) prevents vasospasm. Exacerbations occur in summer (A), nicotine gum (B) still delivers nicotine (harmful), and sunlight (D) is irrelevant.
Which complaint made by the client to the nurse can best be attributed to varicose leg veins?
- A. My legs and feet feel tired after prolonged standing.
- B. My feet perspire heavily during the day.
- C. I wake up at night with a restless feeling in my legs.
- D. I have pain in my shins when I jog.
Correct Answer: A
Rationale: Varicose veins often cause fatigue and heaviness in the legs, especially after prolonged standing, due to impaired venous return.
Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer?
- A. Impaired skin integrity.
- B. Activity intolerance.
- C. Ineffective health maintenance.
- D. Risk for peripheral neuropathy.
Correct Answer: A
Rationale: A foot ulcer in PAD indicates impaired skin integrity (A), the priority due to infection risk. Activity intolerance (B), health maintenance (C), and neuropathy (D) are secondary.
Which question should the nurse ask the male client diagnosed with aortoiliac disease during the admission interview?
- A. Do you have trouble sitting for long periods of time?'
- B. How often do you have a bowel movement and urinate?'
- C. When you lie down, do you feel throbbing in your abdomen?'
- D. Have you experienced any problems having sexual intercourse?'
Correct Answer: D
Rationale: Aortoiliac disease can cause erectile dysfunction due to reduced pelvic blood flow, making sexual intercourse issues (D) relevant. Sitting (A), bowel/urination (B), and throbbing (C) are less specific.
The client with cardiomyopathy is prescribed a beta-blocker. What is the primary purpose of this medication?
- A. Increase heart rate
- B. Reduce cardiac workload
- C. Prevent blood clots
- D. Remove excess fluid
Correct Answer: B
Rationale: Beta-blockers reduce heart rate and myocardial oxygen demand, decreasing cardiac workload.