Nokea
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
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A client admitted to the hospital is suspected of having Guillain-Barré syndrome. Which assessment findings should the nurse identify as manifestations of this disorder? Select all that apply.
- A. Dysphagia
- B. Paresthesia
- C. Facial weakness
- D. Difficulty speaking
- E. Hyperactive deep tendon reflexes
- F. Descending symmetrical muscle weakness
Correct Answer: A,B,C,D
Rationale: Guillain-Barré syndrome is an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. Motor manifestations include ascending symmetrical muscle weakness that leads to flaccid paralysis without muscle atrophy, decreased or absent deep tendon reflexes, respiratory compromise and respiratory failure, and loss of bladder and bowel control. Sensory manifestations include pain (cramping) and paresthesia. Cranial nerve manifestations include facial weakness, dysphagia, diplopia, and difficulty speaking. Autonomic manifestations include labile blood pressure, dysrhythmias, and tachycardia.
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding should the nurse most likely note as an assessment finding in this client?
- A. Tinnitus
- B. Burning in the ear
- C. Itching in the affected ear
- D. Severe pain in the affected ear
Correct Answer: A
Rationale: Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Manifestations of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client's thinking process and attention span. The assessment findings noted in options 2, 3, and 4 are not specifically noted in the client with an inner ear disorder.
A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client's report, the nurse should assess which client data?
- A. Rectal temperature
- B. Last serum potassium
- C. Capillary blood glucose
- D. Serum blood urea nitrogen and creatinine
Correct Answer: C
Rationale: Clients receiving TPN are at risk for hyperglycemia related to the increased glucose load of the solution. The symptoms exhibited by the client are consistent with hyperglycemia. The nurse would need to assess the client's blood glucose level to verify these data. The other options would not provide any information that would correlate with the client's symptoms.
A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment will the nurse perform first?
- A. Level of consciousness
- B. Pulse and blood pressure
- C. Respiratory rate and depth
- D. Ability to move extremities
Correct Answer: C
Rationale: The first action of the nurse is to ensure that the client has an adequate airway and respiratory status. In rapid sequence, the client's circulatory status is evaluated (option 2), followed by evaluation of the status of the cardiovascular and neurological systems.
A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. What should the nurse expect to note on assessment of the client?
- A. Costovertebral angle pain
- B. Absence of any observable signs
- C. Pain, itching, and vaginal discharge
- D. Proteinuria, hematuria, and hypertension
Correct Answer: C
Rationale: Clinical manifestations of a Candida infection include pain; itching; and a thick, white vaginal discharge. Proteinuria and hypertension are signs of preeclampsia. Costovertebral angle pain, proteinuria, and hematuria are clinical manifestations associated with upper urinary tract infections.