Psychosocial Integrity NCLEX | Nurselytic

Correct Answer: C

Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.

Correct Answer: B

Rationale: Guillain-Barré syndrome can lead to respiratory failure due to progressive muscle weakness affecting respiratory muscles, unlike the other conditions.

Correct Answer: B

Rationale: The client needs to wash his hair to remove hair spray, cream, or oil that might interfere with attaching the electrodes to the scalp. Food or fluids do not need to be restricted, with the exception of caffeinated fluids. There is no restriction on metal objects. Aspirin is not a medication that needs to be held before the test (just anticonvulsants, tranquilizers, barbiturates, and other sedatives).

Correct Answer: D

Rationale: Even before the physical assessment (which might or might not be indicated at the time of administration of Vancomycin), ensuring that the client is not allergic to the medication is the most critical action the nurse must take before administering any drug. Lab values regarding renal functioning and therapeutic ranges via peaks and troughs are also important with some medications such as Vancomycin because renal damage can occur if blood drug levels remain high over time.

Correct Answer: B

Rationale: Troponin is the earliest and most specific marker to rise after a myocardial infarction, detectable within hours of cardiac injury.