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A client with symptoms supportive of a diagnosis of Guillain-Barré syndrome.
The nurse knows that which of the following symptoms would be supportive of a diagnosis of Guillain-Barré syndrome?
- A. Hemiplegia, hypertension, tachycardia.
- B. Respiratory failure, flaccid paralysis, urinary retention.
- C. Peripheral edema, hypertension, pulmonary congestion.
- D. Diminished reflexes, pain, paresthesia.
Correct Answer: B
Rationale: Strategy: All parts of the answer choice must be correct in order for the answer to be correct. (1) relates to a CVA (2) correct-classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation (3) relates to pulmonary edema (4) relates to peripheral nerve problems
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An adult has recently been diagnosed with chronic obstructive pulmonary disease (COPD). All of the following goals are in the teaching plan. Which will probably be most difficult for the client to achieve?
- A. Stop smoking within three months
- B. Demonstrate pursed lip breathing technique within one week
- C. Drink 2 L of fluid each day
- D. Receive vaccinations against flu and pneumonia within one month
Correct Answer: A
Rationale: Smoking cessation is the most challenging due to nicotine addiction, despite being critical for COPD management, compared to learning breathing techniques, hydration, or vaccinations.
Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach?
- A. Consider a liquid supplement to increase calories
- B. Discuss consequences of an unbalanced diet with the child
- C. Provide fruit, vegetable and protein snacks
- D. Encourage the child to keep a daily log of foods eaten
Correct Answer: B
Rationale: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to appropriate diet, and the problems that might arise if diet is not adequate.
The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
- A. Daily needs and concerns
- B. The overview cardiac rehabilitation
- C. Medication and diet guideline
- D. Activity and rest guidelines
Correct Answer: A
Rationale: At 2 days post-MI, the client's education should be focused on the immediate needs and concerns for the day.
A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent.
Which of these responses by the nurse would be BEST?
- A. These things always have a way of working themselves out.'
- B. It's important for your health that you not worry too much.'
- C. You're worried that you won't be able to pay the rent?'
- D. A social worker might be able to help you with this problem.'
Correct Answer: C
Rationale: Strategy: 'BEST' indicates there may be more than one response you will like. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoid feelings (3) correct-reflective response, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic
The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:
- A. above the clitoris.
- B. behind the vagina.
- C. between the clitoris and the vagina.
- D. between the vagina and the rectum.
Correct Answer: C
Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.