The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client’s room?

Nebulizer and pulse oximeter.

Blood pressure cuff and flashlight.

Nasal cannula and incentive spirometer.

Electrocardiographic monitoring electrodes and intubation tray.

Answer and Explanation

The Correct Answer is D

Choice A reason: Nebulizer and pulse oximeter monitor breathing but are less critical than preparing for respiratory failure, a Guillain-Barré complication. Intubation equipment is essential, making this incorrect, as it’s secondary to the nurse’s priority of addressing potential airway compromise in the client.

Choice B reason: Blood pressure cuff and flashlight are useful but don’t address the risk of respiratory paralysis in Guillain-Barré. Intubation tray is critical, making this incorrect, as it’s less urgent than the nurse’s need to prepare for life-threatening respiratory complications in the client.

Choice C reason: Nasal cannula and spirometer support breathing but are inadequate for acute respiratory failure in Guillain-Barré. Electrocardiographic and intubation equipment are vital, making this incorrect, as it doesn’t prioritize the nurse’s preparation for the client’s potential rapid respiratory deterioration.

Choice D reason: Electrocardiographic electrodes and intubation tray are essential for Guillain-Barré, as ascending paralysis risks respiratory failure and autonomic dysfunction. This aligns with neurological emergency protocols, making it the correct choice for the nurse to bring to manage life-threatening complications effectively.

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Correct Answer is C

Explanation

Choice A reason: Lithium can cause nephrogenic diabetes insipidus, not SIADH, which involves excess ADH. Lung cancer is a known SIADH trigger, making this incorrect, as it’s unrelated to the syndrome compared to the high-risk client with cancer and vincristine therapy.

Choice B reason: Losartan treats hypertension in renal artery stenosis but doesn’t cause SIADH, which is linked to cancers. Lung cancer with vincristine is riskier, making this incorrect, as it’s not associated with the syndrome in the nurse’s risk assessment of clients.

Choice C reason: Lung cancer, especially small cell, and vincristine are strongly associated with SIADH due to ectopic ADH production. This aligns with oncology risk factors, making it the correct client most at risk for SIADH in the nurse’s outpatient clinic care.

Choice D reason: Hyperthyroidism and methimazole don’t typically cause SIADH, unlike lung cancer’s strong link. Vincristine-treated cancer is the highest risk, making this incorrect, as it’s not a primary cause of SIADH in the nurse’s evaluation of the outpatient clients.

A. A low-fat diet. B. A low-fiber diet. C. A high-protein diet. D. A high-carbohydrate diet.

Correct Answer is B

Explanation

Choice A reason: A low-fat diet benefits gallbladder issues, not acute diverticulitis, which requires reduced bowel stimulation. A low-fiber diet prevents irritation, making this incorrect, as it’s less relevant than the nurse’s anticipated prescription for managing acute diverticulitis symptoms effectively.

Choice B reason: A low-fiber diet is prescribed for acute diverticulitis to rest the colon and reduce irritation of inflamed diverticula. This aligns with gastrointestinal treatment protocols, making it the correct diet the nurse would anticipate for the client’s acute diverticulitis management.

Choice C reason: A high-protein diet supports healing but isn’t specific for acute diverticulitis, which needs low fiber to avoid irritation. Low-fiber is correct, making this incorrect, as it’s not the primary diet the nurse expects for managing acute diverticulitis symptoms.

Choice D reason: A high-carbohydrate diet may increase bowel activity, worsening acute diverticulitis. A low-fiber diet reduces stimulation, making this incorrect, as it’s inappropriate compared to the nurse’s anticipated prescription for a diet to manage acute diverticulitis effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Correct Answer is C

Explanation

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

Correct Answer is B

Explanation

A nurse is admitting a client with pneumonia. Which of the following orders should be implemented first?

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)

Which situations are early signs of an ethical dilemma? (Select all that apply)

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? (Select all that apply)

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

The nurse is assessing the patency of a client’s left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?