Nokea
While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?
- A. A spinal cord injury at age 12
- B. An upper respiratory infection about a month ago
- C. Hydrocephaly as an infant
- D. A joint injury as a teenager
Correct Answer: B
Rationale: Guillain-Barre Syndrome is often triggered by a recent infection, commonly an upper respiratory infection, leading to an autoimmune response against peripheral nerves. Spinal cord injury, hydrocephaly, and joint injury are unrelated.
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The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority?
- A. Wound and skin integrity
- B. Mobility assessment
- C. Skin and vascular assessment
- D. Circulation and sensation
Correct Answer: D
Rationale: Circulation and sensation are the priority post-arthroscopy to detect neurovascular compromise, such as nerve damage or impaired blood flow, which can be urgent. Wound, mobility, and skin are important but secondary.
The nurse reviews the client's clinical data. Which action should the nurse take based on the clinical data?
- A. Administer the prescribed ketorolac
- B. Remove the heating pad from the client's lower back
- C. Contact the physician to question the prescription of ketorolac
- D. Reposition the client to the side of the bed and have them twist from side to side
- E. Remove and discard the prescribed fentanyl patch because of its lack of efficacy
Correct Answer: B
Rationale: Removing the heating pad is appropriate, as heat can worsen inflammation or strain in low back pain. Ketorolac may be suitable, twisting risks harm, and fentanyl efficacy needs more data before removal.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 3 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
The nurse reviews the consultation report from the infectious disease physician. Select the complications that the client is at risk for developing? Select all that apply.
- A. Rheumatoid arthritis
- B. Osteosarcoma
- C. Avascular necrosis
- D. Sepsis
- E. Paget's disease
- F. Hyperosmolar hyperglycemic nonketotic syndrome
Correct Answer: C, D
Rationale: With suspected osteomyelitis and uncontrolled diabetes, the client risks avascular necrosis due to poor blood supply and sepsis from untreated infection spreading. Rheumatoid arthritis and osteosarcoma are unrelated, and Paget's is a chronic bone disorder.
The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the bedside?
- A. Calcium gluconate
- B. Bag-valve mask
- C. Tracheostomy kit
- D. Atropine sulfate
Correct Answer: B
Rationale: Myasthenia gravis can cause respiratory muscle weakness, and post-thymectomy risks respiratory compromise. A bag-valve mask is critical for emergency ventilation. Calcium gluconate, tracheostomy kits, and atropine are not directly related.
The nurse reviews the client's clinical data. Which action should the nurse take based on the clinical data?
- A. Administer the prescribed ketorolac
- B. Remove the heating pad from the client's lower back
- C. Contact the physician to question the prescription of ketorolac
- D. Reposition the client to the side of the bed and have them twist from side to side
- E. Remove and discard the prescribed fentanyl patch because of its lack of efficacy
Correct Answer: B
Rationale: Removing the heating pad is appropriate, as heat can worsen inflammation or strain in low back pain. Ketorolac may be suitable, twisting risks harm, and fentanyl efficacy needs more data before removal.