Nokea
The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action?
- A. Assessing respiratory status frequently.
- B. Administering intravenous immunoglobulin (IVIG) as prescribed.
- C. Providing passive range of motion exercises to maintain joint mobility.
- D. Monitoring for autonomic dysreflexia.
Correct Answer: A
Rationale: Frequent respiratory status assessment (A) is the priority in GBS due to the risk of respiratory muscle paralysis. IVIG (B) is a treatment, not a nursing action priority. Range of motion exercises (C) and autonomic dysreflexia monitoring (D) are secondary concerns.
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The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 6 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
- A. I should limit my exposure to direct sunlight to 45 continuous minutes each day.
- B. I should wear long sleeves and a large-brimmed hat when outdoors.
- C. I should wash my skin with an antibacterial soap.
- D. Cosmetics must be selected carefully and should include moisturizers and sun protectors.
- E. I should refrain from receiving any vaccine.
Correct Answer: B,D
Rationale: Wearing long sleeves and a large-brimmed hat (B) and using cosmetics with moisturizers and sun protectors (D) indicate understanding of photoprotection, crucial for SLE to prevent rash exacerbation. Limiting sun exposure to 45 minutes (A) is too specific and risky, antibacterial soap (C) is unnecessary, and avoiding all vaccines (E) is incorrect as some are safe.
The nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include?
- A. 0.9% saline should be infused once vascular access is established.
- B. The initial treatment is intravenous diphenhydramine.
- C. The client should carry a prefilled syringe of hydrocortisone.
- D. If shock occurs, the client should be positioned in reverse Trendelenburg.
Correct Answer: A
Rationale: 0.9% saline infusion (A) is critical in anaphylaxis to restore volume in shock. Epinephrine, not diphenhydramine (B), is the initial treatment. Clients carry epinephrine (not hydrocortisone, C) in auto-injectors. Reverse Trendelenburg (D) is incorrect; flat or leg-elevated positioning is preferred.
The nurse is discussing the underlying mechanism of psoriasis with a client recently diagnosed with the condition. The nurse explains that psoriasis is primarily associated with?
- A. overactivity of the immune system targeting healthy skin cells.
- B. deficiency of T lymphocytes leading to skin inflammation.
- C. impaired production of melanocytes causing skin discoloration.
- D. excessive sebum production resulting in follicular plugging.
Correct Answer: A
Rationale: Psoriasis is caused by overactivity of the immune system, particularly T cells, attacking healthy skin cells (A), leading to rapid skin turnover and plaques. T lymphocyte deficiency (B) is unrelated, melanocyte issues (C) cause pigmentation changes, and excessive sebum (D) is linked to acne.
The nurse suspects the client is experiencing ………………… which is classified as a(n) ……………………………
- A. rheumatoid arthritis
- B. multiple sclerosis
- C. erythematosus (SLE)
- D. anaphylaxis
- E. myasthenia gravis
- F. Hypersensitivity disorder
- G. Autoimmune disorder
Correct Answer: C,G
Rationale: The symptoms of fatigue, joint pain, facial rash worsened by sun exposure, fever, and swelling are classic for systemic lupus erythematosus (SLE) (C), an autoimmune disorder (I). Rheumatoid arthritis (A) lacks the photosensitive rash, multiple sclerosis (B) involves neurological symptoms, anaphylaxis (D) is acute, and myasthenia gravis (E) causes muscle weakness.
A client in the medical ward developed sudden hypotension, difficulty breathing, and cyanosis shortly after receiving an intravenous penicillin infusion. Based on the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction?
- A. Potent antibodies formed when the antibiotic was infused into the client during this infusion.
- B. The client was previously exposed to penicillin, enabling their body to produce antibodies.
- C. The client developed passive immunity to penicillin.
- D. Atopic sensitization occurred.
Correct Answer: B
Rationale: Anaphylaxis occurs due to prior exposure to penicillin (B), leading to IgE antibody production and a rapid allergic response upon re-exposure. Antibodies don't form instantly during infusion (A), passive immunity (C) involves transferred antibodies, and atopic sensitization (D) is a predisposition, not the direct cause.