The emergency room nurse suspects a client has botulism. Which findings support the nurse's suspicion? Select all that apply.
Nuchal rigidity
Ptosis
Dysphagia
Fever
Diplopia
Correct Answer : B,C,E
Rationale:
A. Nuchal rigidity, or stiffness of the neck, is a hallmark sign of meningeal irritation such as in meningitis, not botulism. While it is a neurological finding, it is not associated with the neuroparalytic effects of botulism.
B. Ptosis (drooping of the eyelids) is a classic early sign of botulism. Botulinum toxin blocks acetylcholine release at neuromuscular junctions, leading to descending flaccid paralysis, which often begins with cranial nerves. Ptosis is a direct result of this cranial nerve involvement.
C. Dysphagia (difficulty swallowing) occurs because botulinum toxin impairs the muscles involved in swallowing. This is another common early manifestation, reflecting bulbar muscle involvement.
D. Fever is generally not present in botulism. Botulism is a toxin-mediated disease rather than an infectious or inflammatory process that triggers systemic fever. Presence of fever might suggest another infection.
E. Diplopia (double vision) results from paralysis of extraocular muscles, which is another early cranial nerve sign of botulism. It reflects the neurotoxin’s effect on the neuromuscular junction of eye muscles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The primary principle in any situation involving electricity is safety. The client has already reported feeling an electric shock, which indicates that the device is still potentially hazardous. The first step must be to eliminate the source of danger by unplugging the radio or ensuring it is no longer connected to electricity. This protects both the client and anyone else in the area from further injury. Safety always takes precedence over assessment or administrative tasks.
B. While taking an apical pulse is important after an electric shock to assess for arrhythmias or other cardiac effects, it is secondary to removing the hazard. Performing an assessment while the source of electricity is still present could put the nurse or client at additional risk. Once the radio is disconnected and the client is safe, the nurse should then immediately assess cardiac status, including pulse, heart rhythm, and vital signs.
C. Having the maintenance department check the device is necessary to prevent future hazards, but it is a later action, not the first priority. Immediate safety and assessment of the client’s condition take precedence over administrative follow-up.
D. Inspecting for burns or other injuries is essential, as electric shocks can cause external burns, internal tissue damage, or cardiac complications, but again, it is secondary. The nurse must first remove the source of electricity to prevent additional injury. After the device is disconnected, the nurse can safely evaluate for burns, neurological changes, or other complications.
Correct Answer is ["100"]
Explanation
Step 1: Identify total volume and time
Total volume = 50 mL, Time = 30 minutes = 0.5 hours
Step 2: Use the formula
mL/hour = Total volume ÷ Time (in hours)
Step 3: Insert values
= 50 ÷ 0.5
Step 4: Calculate
= 100 mL/hour
Final Answer: 100
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