Nokea
The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem 'impaired physical mobility.' Which long-term goal should be written for this problem?
- A. The client will have no skin irritation.
- B. The client will have no muscle atrophy.
- C. The client will perform range-of-motion exercises.
- D. The client will turn every two (2) hours while awake.
Correct Answer: C
Rationale: Performing range-of-motion exercises is a measurable long-term goal to improve mobility. Skin irritation, atrophy prevention, and turning are interventions, not goals.
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The concept of impaired immunity has been identified by the nurse as it applies to the client diagnosed with Acquired Immune Deficiency Syndrome (AIDS). Which interventions should the nurse implement?
- A. Keep fresh flowers and raw vegetables out of the client's room.
- B. Have the Unlicensed Assistive Personnel (UAP) assist with ADLs.
- C. Encourage the client to perform active range of motion.
- D. Teach the client about the cardiovascular medications.
Correct Answer: A
Rationale: Avoiding flowers and raw vegetables reduces infection risk in AIDS. UAP assistance, ROM, and cardiovascular teaching are unrelated to immunity.
The wife of a client diagnosed with myasthenia gravis is crying and shares with the nurse she just doesn't know what to do. Which response is the best action by the nurse?
- A. Discuss the Myasthenia Foundation with the client's wife.
- B. Refer the client to a local myasthenia gravis support group.
- C. Ask the client's wife if she would like to talk to a counselor.
- D. Sit down and allow the wife to ventilate her feelings to the nurse.
Correct Answer: D
Rationale: Allowing the wife to ventilate feelings is therapeutic, addressing immediate emotional distress. Foundation discussion, support groups, and counseling are secondary.
The client who has engaged in needle-sharing activities has developed a flu-like illness. An HIV antibody test is negative. Which statement best describes the scientific rationale for this finding?
- A. The client is fortunate not to have contracted HIV from an infected needle.
- B. The client must be repeatedly exposed to HIV before becoming infected.
- C. The client may be in the primary infection phase of an HIV infection.
- D. The antibody test is negative because the client has a different flu virus.
Correct Answer: C
Rationale: A negative antibody test during flu-like symptoms may indicate the primary HIV infection phase, before seroconversion. Single exposure can infect, and flu viruses are unrelated.
The client diagnosed with an anaphylactic reaction is admitted to the emergency department. Which assessment data indicate the client is not responding to the treatment?
- A. The client has a urinary output of 120 mL in two (2) hours.
- B. The client has an AP of 110 and a BP of 90/60.
- C. The client has clear breath sounds and an RR of 26.
- D. The client has hyperactive bowel sounds.
Correct Answer: B
Rationale: Hypotension (BP 90/60) and tachycardia (AP 110) indicate ongoing anaphylaxis despite treatment. Normal urine output, clear lungs, and bowel sounds suggest improvement.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.