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Tom has Guillain-Barré syndrome and asks what causes his burning, prickling feeling. You respond by saying
- A. You are lying too long on the affected side.
- B. This is in response to your medication.
- C. The myelin cover of the nerve endings is absent.
- D. This is secondary to dysphagia.
Correct Answer: C
Rationale: Guillain-Barré syndrome damages the myelin sheath, leading to abnormal sensations.
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A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.
Which type of agent does sulfur mustard fall under?
- A. Nerve agents
- B. Blistering agents
- C. Respiratory toxins
- D. Cyanide poisonings
Correct Answer: B
Rationale: The correct answer is B because sulfur mustard is a blistering agent that causes skin and respiratory damage.
Which communication technique will help a nurse communicate with clients who do not speak English?
- A. Repeat the question without changing words.
- B. Look at the translator when asking questions.
- C. Speak slowly,using simple words and short sentences.
- D. Refer to an English or foreign language dictionary for bilingual words.
Correct Answer: C
Rationale: Speaking slowly and using simple language improves comprehension for non-native speakers.
Tom reports a history of carpal tunnel syndrome. What else would you expect to find in his history?
- A. Crepitus (grating feeling on palpation over joint during range of motion) due to loss of articular cartilage and bony overgrowth in joint.
- B. Excessive forward curvature of the thoracic spine (kyphosis) due to pathologic vertebral fractures and collapsing of the anterior portion of the vertebral bodies in the thoracic area.
- C. Pain and numbness or tingling sensation in the hand over the palmar surface of the thumb, index, and middle fingers, and lateral aspect of the ring finger, that is worse at night.
- D. Acute onset of excruciating pain in joint due to accumulation of uric acid within the joint.
Correct Answer: C
Rationale: Carpal tunnel syndrome affects the median nerve, causing pain and numbness in specific areas.
In most states, directives to physicians, durable power of attorney for health care, and medical power of attorney are included in which legal documents?
- A. Natural death acts
- B. Allow natural death
- C. Advance care planning
- D. Do Not Resuscitate order.
Correct Answer: C
Rationale: Advance care planning encompasses various legal documents that outline a person's healthcare preferences and appoints proxies to make decisions on their behalf when incapacitated.