The nurse is caring for a client with Guillain-BarrÃ© syndro...

The nurse is caring for a client with Guillain-BarrÃ© syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?

A. Diaphoresis with facial flushing
B. Hypoactive or absent bowel sounds
C. Inability to cough or lift the head
D. Warm, tender, and swollen leg

Correct Answer: C

Rationale: Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-BarrÃ© syndrome, making it the priority.

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Which finding by the nurse suggests that the mother is not giving the toddler iron supplements as ordered?

A. The child has pale skin.
B. There is light brown stool in the diaper.
C. The child takes a nap every day.
D. The child has ecchymotic areas on her legs.

Correct Answer: B

Rationale: Iron supplements typically cause dark or black stools; light brown stools suggest non-compliance with iron supplementation.

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?

A. Encourage the night nurse to provide the UAP with additional training
B. Indicate that it is the night nurse's job to deal with staff problems
C. Remind the night nurse that the UAP is doing the best job the UAP can
D. Suggest that the night nurse discuss concerns with the nurse manager

Correct Answer: D

Rationale: Suggesting discussion with the nurse manager (D) addresses the issue professionally. Encouraging training (A), deflecting responsibility (B), or defending the UAP (C) are less appropriate.

A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

A. Document this communication in the electronic health record
B. Encourage the client to discuss this decision with the health care proxy
C. Facilitate completion of an advance directive that reflects the client's decision
D. Obtain a signed informed consent from the client
E. Tell the health care provider (HCP) that the client needs a do-not-resuscitate (DNR) order

Correct Answer: A, B, C

Rationale: Documenting in the EHR (A), discussing with the proxy (B), and completing an advance directive (C) ensure the client's wishes are communicated. Informed consent (D) is irrelevant, and DNR (E) is not indicated.

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.

A. Blood pressure 82/64 mm Hg
B. Crackles on auscultation
C. Distended jugular veins
D. Pulse 120/min
E. Shoulder pain

Correct Answer: A, D, E

Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply.

A. Guide the client to the floor and gently cradle the head
B. Insert a tongue blade to prevent client from swallowing the tongue
C. Move objects that may cause injury away from the client
D. Physically restrain the client to prevent injury
E. Place the client in left lateral position
F. Remain with the client, observe, and record the seizure activity

Correct Answer: A, C, E, F

Rationale: Guiding to the floor (A), clearing objects (C), positioning laterally (E), and observing (F) ensure safety. Tongue blades (B) are dangerous, and restraining (D) increases injury risk.