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The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.
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The employee health nurse is teaching a class on 'Preventing Eye Injury.' Which information should be discussed in the class?
- A. Read instructions thoroughly before using tools and working with chemicals.
- B. Wear some type of glasses when working around flying fragments.
- C. Always wear a protective helmet with eye shield around dust particles.
- D. Pay close attention to the surroundings so eye injuries will be prevented.
Correct Answer: A
Rationale: Reading instructions ensures safe tool and chemical use, preventing eye injuries. Glasses are specific, helmets are not always required, and attention is vague.
An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
- A. Inform him that this is a common side effect of phenytoin (Dilantin) therapy
- B. Test the urine for occult blood
- C. Report it to the physician because it could indicate a clotting deficiency
- D. Send a urine specimen to the lab
Correct Answer: A
Rationale: Phenytoin commonly causes reddish-brown urine, a benign side effect, so informing the client is appropriate. Testing or reporting is unnecessary unless other symptoms suggest a problem.
The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?
- A. Has your ability to perceive colors changed?
- B. Does your vision appear distorted or wavy?
- C. Does the center of your visual field appear dark?
- D. Do you see random flashes of bright light?
Correct Answer: A
Rationale: Asking about a change in the ability to perceive colors will help in determining cataract development. Cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors. Distorted central vision is a sign of macular degeneration. A darkened area in the center of the visual field is associated with macular degeneration. Seeing flashes of bright lights is associated with retinal detachment.
The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?
- A. Tympanometry
- B. Arteriogram of the cranial vessels
- C. Magnetic resonance imaging (MRI)
- D. Auditory canal biopsy
Correct Answer: C
Rationale: MRI with gadolinium enhancement is the most reliable test in determining size and anatomical location of an acoustic neuroma. Tympanometry, arteriogram, and biopsy are not used for this diagnosis.
The client is scheduled for ear surgery. Which statement indicates the client needs more preoperative teaching concerning the surgery?
- A. If I have to sneeze or blow my nose, I will do it with my mouth open.
- B. I may get dizzy after the surgery, so I must be careful when walking.
- C. I will probably have some hearing loss after surgery, but hearing will return.
- D. I can shampoo my hair the day after surgery as long as I am careful.
Correct Answer: D
Rationale: Shampooing the day after ear surgery risks water entry and infection; typically, hair washing is delayed. Open-mouth sneezing, dizziness, and temporary hearing loss are correct.