Nokea
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
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The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
On the basis of the factors that cause the client to experience paroxysmal pain, which intervention is most appropriate to include in this client's care plan?
- A. Direct a fan toward the client's face.
- B. Avoid care that involves touching the client's face.
- C. Apply ice packs to the client's face.
- D. Apply warm facial compresses for pain.
Correct Answer: B
Rationale: Avoiding facial touch minimizes triggering paroxysmal pain in trigeminal neuralgia, which is sensitive to tactile stimuli.
When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.