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When the nursing team plans the care of a client with Guillain-Barré syndrome, which assessment finding most accurately determines whether the client is developing ineffective breathing?
- A. Respiratory rate is 24.
- B. Skin is flushed.
- C. Activity is decreased.
- D. Pulse oximetry reading is 82%.
Correct Answer: D
Rationale: A pulse oximetry reading of 82% indicates significant hypoxemia, suggesting ineffective breathing, which is a critical concern in Guillain-Barré syndrome due to potential respiratory muscle weakness.
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The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke?
- A. A 92-year-old client who is an alcoholic.
- B. A 54-year-old client diagnosed with hepatitis.
- C. A 60-year-old client who has a Greenfield filter.
- D. A 68-year-old client with chronic atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation (D) increases stroke risk due to clot formation. Age (A) is a factor but less specific, hepatitis (B) is unrelated, and Greenfield filters (C) prevent pulmonary embolism, not stroke.
The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?
- A. Refer the child for genetic counseling as soon as possible.
- B. Teach the child to use a warming tray under the food during meals.
- C. Discuss the importance of not abandoning the parent.
- D. Allow the child to talk about the fear of getting the disease.
Correct Answer: D
Rationale: Huntington’s has a 50% genetic risk. Allowing the child to express fears (D) addresses psychosocial needs therapeutically. Genetic counseling (A) is appropriate but secondary, warming trays (B) are irrelevant, and abandonment discussions (C) may guilt-trip.
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- A. Note the first thing the client does in the seizure.
- B. Assess the size of the client’s pupils.
- C. Determine if the client is incontinent of urine or stool.
- D. Provide the client with privacy during the seizure.
Correct Answer: A
Rationale: Noting the first action (A) helps identify the seizure type and focus, aiding diagnosis and treatment. Pupil size (B), incontinence (C), and privacy (D) are secondary to ensuring safety and documenting the event.
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
- A. Assess lung sounds.
- B. Assess the six cardinal fields of gaze.
- C. Assess apical pulse.
- D. Assess level of consciousness.
Correct Answer: D
Rationale: Level of consciousness (D) is the priority assessment in meningitis, as it indicates neurological status and potential complications like increased ICP. Lung sounds (A), eye movements (B), and pulse (C) are secondary.