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Which sign/symptom should the nurse expect to assess in the client who is in the recovery stage of Guillain-Barré syndrome?
- A. Decreasing deep tendon reflexes.
- B. Drooping of the eyelids has resolved.
- C. A positive Babinski's reflex.
- D. Descending increase in muscle strength.
Correct Answer: D
Rationale: Recovery in Guillain-Barré syndrome shows descending muscle strength improvement. Reflexes improve, ptosis is unrelated, and Babinski’s is not typical.
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The nurse is explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS?
- A. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident.
- B. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature.
- C. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria.
- D. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
Correct Answer: B
Rationale: SIRS is a systemic response to various insults (e.g., infection, trauma, surgery), not limited to specific causes. Burns, infections, and allergies are subsets.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?
- A. Assign a different nurse every shift to the client.
- B. Ask the HCP to tell the client not to yell at the staff.
- C. Call a team meeting and discuss options with the staff.
- D. Tell one (1) staff member to care for the client a week at a time.
Correct Answer: C
Rationale: A team meeting fosters collaboration to address the client’s behavior and staff concerns. Rotating nurses, HCP intervention, or single-nurse assignment are less effective.
Which type of isolation technique is designed to decrease the risk of transmission of recognized and unrecognized sources of infections?
- A. Contact Precautions.
- B. Airborne Precautions.
- C. Droplet Precautions.
- D. Standard Precautions.
Correct Answer: D
Rationale: Standard Precautions reduce transmission of all infections by assuming all patients are infectious. Contact, airborne, and droplet precautions are for specific transmission modes.
The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE?
- A. Pericardial friction rub and crackles in the lungs.
- B. Muscle spasticity and bradykinesia.
- C. Hirsutism and clubbing of the fingers.
- D. Somnolence and weight gain.
Correct Answer: A
Rationale: Pericardial friction rub and lung crackles indicate serositis, common in SLE. Spasticity, hirsutism, and somnolence suggest other conditions.
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
- A. Prepare to administer Solu-Medrol, a glucocorticoid, IV.
- B. Request and obtain a STAT chest x-ray.
- C. Initiate the rapid response team.
- D. Administer epinephrine, an adrenergic blocker, SQ then IV continuous.
- E. Assess the client's pulse and respirations.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.