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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A nurse is taking care of a client that is status-post hand arthroplasty. When creating the care plan, which of the following nursing interventions should be avoided to prevent complications?
- A. Encourage the client to perform finger and wrist exercises ten times per hour, using a full range of flexion and extension.
- B. Place the client's personal items within reach of the client's non-operative arm.
- C. Place the client's operative arm on a pillow to rest and keep it elevated.
- D. Encourage the client to use the non-operative arm as much as possible.
Correct Answer: A
Rationale: Excessive full range of motion exercises shortly after hand arthroplasty can strain the surgical site, risking damage or delayed healing. Elevation, using the non-operative arm, and placing items within reach are appropriate.
The nurse is caring for a client experiencing an exacerbation of rheumatoid arthritis (RA). The nurse should obtain a prescription for
- A. Allopurinol.
- B. Verapamil.
- C. Prednisone.
- D. Methotrexate.
Correct Answer: C, D
Rationale: Prednisone (a corticosteroid) reduces acute inflammation, and methotrexate (a DMARD) manages chronic rheumatoid arthritis. Allopurinol treats gout, and verapamil is for cardiac issues.
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
- A. Stabilize the knee joint during ambulation
- B. Promote knee flexion
- C. Reduce post-surgical swelling
- D. Prevent blood clots
Correct Answer: B
Rationale: The primary purpose of a CPM device is to promote knee flexion and range of motion post-surgery, aiding recovery. It doesn't stabilize during ambulation, primarily reduce swelling, or prevent clots.
The nurse is assessing a client who is newly diagnosed with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis?
- A. Janeway lesions
- B. Tophi
- C. Unilateral joint pain
- D. Low-grade fever
Correct Answer: D
Rationale: Low-grade fever is consistent with rheumatoid arthritis, a systemic inflammatory condition. Janeway lesions are linked to endocarditis, tophi to gout, and RA typically involves bilateral joint pain.
The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care?
- A. Pin care every shift
- B. Neck flexion and extension exercises
- C. Taping the wrench to the vest
- D. Report loosening of the pins
- E. Use straws when providing liquids
Correct Answer: A, D, E
Rationale: Pin care prevents infection, reporting loose pins ensures stability, and straws aid safe drinking. Neck exercises are contraindicated as they risk spinal injury, and taping the wrench is standard but not always required unless specified.