- (Topic 4)
A 32-year-old female client is being treated for Guillain- Barr?? 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?

1. A. Complaints of a headache
2. B. Loss of superficial and deep tendon reflexes
3. C. Complaints of shortness of breath
4. D. Facial paralysis

Correct Answer: C
(A) Headaches are not associated with Guillain-Barr?? syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) 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. (D) Facial paralysis is expected and is not considered abnormal.

- (Topic 7)
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?

1. A. ??If you forget to take your morning dose, double the night time dose.??
2. B. ??You should take aspirin instead of acetaminophen (Tylenol) for headaches.??
3. C. ??Carry a medications alert card with you at all times.??
4. D. ??You should use a straight-edge razor when shaving your arms and legs.??

Correct Answer: C
(A) Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. (B) Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. (C) Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. (D) An electric razor should be used to prevent accidental cutting, which can lead to bleeding.

- (Topic 4)
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, ??Can??t you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.?? At this time the nurse??s greatest concern is that:

1. A. The client may contract an infection as a result of being exposed to large crowds at spring break
2. B. The client does not grasp the full impact of her illness
3. C. The client may require transfusion before leaving for spring break
4. D. The causative agent be identified and treatment begun

Correct Answer: B
(A) The client could contract an infection, but at this point it is not the most pertinent issue.
(B) The client??s statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.

- (Topic 4)
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

1. A. Decreased cardiac output related to excessive bleeding
2. B. Potential for fluid volume excess related to fluid resuscitation
3. C. Anxiety related to threat to self
4. D. Alteration in parenting related to potential fetal injury

Correct Answer: A
(A) Based on the client??s history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. (B) This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. (C) The client??s expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. (D) Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.

- (Topic 2)
A client is admitted to the hospital for an induction of labor owing to a gestation of 42 weeks confirmed by dates and ultrasound. When she is dilated 3 cm, she has a contraction of 70 seconds. She is receiving oxytocin.
The nurse??s first intervention should be to:

1. A. Check FHT
2. B. Notify the attending physician
3. C. Turn off the IV oxytocin
4. D. Prepare for the delivery because the client is probably in transition

Correct Answer: C
(A) FHT should be monitored continuously with an induction of labor; this is an accepted standard of care. (B) The physician should be notified, but this is not the first intervention the nurse should do. (C) The standard of care for an induction according to the Association of Women??s Health, Obstetric, and Neonatal Nurses and American College of Obstetrics and Gynecology is that contractions should not exceed 60 seconds in an induction. Inductions should simulate normal labor; 70-second contractions during the latent phase (3 cm) are not the norm. The next contractions can be longer and increase risks to the mother and fetus. (D) Contractions lasting 60–90 seconds during transition are typical; this provides a good distractor. The nurse needs to be knowledgeable of the phases and stages of labor.