Nokea
The nurse is admitting a client with a diagnosis of Guillain-Barre syndrome. During the history taking, the nurse should ask if the client has recently experienced which physical problem?
- A. Meningitis
- B. Seizures or head trauma
- C. A back injury or spinal cord trauma
- D. A respiratory or gastrointestinal (GI) infection
Correct Answer: D
Rationale: Guillain-Barre syndrome is a clinical condition of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally it has been triggered by vaccination or surgery. The other options are not associated with an incidence of this syndrome.
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A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
- A. Consult the pharmacist regarding identification of the medications.
- B. Show pictures to the client from the Physician's Desk Reference to identify the medications.
- C. Consult the previous medical record and notify the physician regarding medications that must be ordered.
- D. Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Correct Answer: D
Rationale: Having medications brought in original vials ensures accurate identification, promoting safe administration.
You are working as a National Board for Certification of Hospice and Palliative Nurses certified hospice and palliative care nurse who is caring for your clients in their home. Which of the following nursing diagnoses or client goal would be the most likely appropriate and expected for the vast majority of these clients?
- A. The client will accept impending death
- B. Guilt related to past transgressions
- C. Spiritual distress related to guilt
- D. Pain related to end of life symptoms
Correct Answer: A
Rationale: Accepting impending death is a common and appropriate goal for hospice clients, as it aligns with the focus of palliative care on achieving peace and closure at the end of life.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
You are having a nice dinner in a fancy restaurant. As you are eating, you hear the gentleman eating at the next table start to bang the table, hold his throat and forcibly cough. What should you do?
- A. Perform the Valsalva maneuver
- B. Encourage the person to continue coughing
- C. Perform the Heimlich maneuver
- D. Begin CPR and prepare for ACLS measures
Correct Answer: B
Rationale: Forcing coughing suggests a partial airway obstruction. Encouraging the person to continue coughing is the first step to dislodge the obstruction without invasive intervention.