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Questions 158

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Question 1 of 5

A 32-year-old female client is being treated for Guillain-Barré syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty in ambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Correct Answer: C

Rationale: Headaches are not associated with Guillain-Barré syndrome. Loss of superficial and deep tendon reflexes is expected with this diagnosis. Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. Facial paralysis is expected and is not considered abnormal.

Question 2 of 5

The mother of a one-year-old with sickle cell anemia wants to know why the condition didn't show up in the nursery. The nurse's response is based on the knowledge that:

Correct Answer: D

Rationale: Fetal hemoglobin (HbF), predominant in newborns, inhibits sickling in sickle cell anemia, delaying symptoms until HbF decreases around 6 months. Newborn screening exists, and infections can trigger crises later.

Question 3 of 5

Which of the following serum laboratory values would the nurse monitor during gentamicin therapy?

Correct Answer: A

Rationale: A common side effect of gentamicin is nephrotoxicity. The serum laboratory test that best reflects kidney function is serum creatinine.

Question 4 of 5

The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:

Correct Answer: A

Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.

Question 5 of 5

Which assignment should not be delegated to the licensed practical nurse?

Correct Answer: D

Rationale: Starting a blood transfusion requires RN-level assessment and monitoring due to the risk of transfusion reactions, which is outside the LPN’s scope in most settings. Foley insertion, NG tube discontinuation, and sputum collection are within LPN scope.

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