ANSWERS
Which assessment is most important for the nurse to perform on a client who is
hospitalized for Guillain-Barre syndrome that is rapidly progressing?
Respiratory effort.
Unsteady gait.
Intensity of pain.
Ability to eat. - Correct answer- Respiratory effort.
Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and
progresses upwards. As the condition progresses, the nurse must ensure that the client
is able to breathe effectively.
A male client comes into the clinic with a history of penile discharge with painful,
burning urination. Which action should the nurse implement?
Collect a culture of the penile discharge.
Palpate the inguinal lymph nodes gently.
Observe for scrotal swelling and redness.
Express the discharge to determine color. - Correct answer- Collect a culture of the
penile discharge.
, Penile discharge with painful urination is commonly associated with gonorrhea. The
nurse should collect a culture of the penile discharge to determine the cause of these
symptoms. The cause must be determined or confirmed through culture to identify the
organism and ensure effective treatment.
A client with history of atrial fibrillation is admitted to the telemetry unit with sudden
onset of shortness of breath. The nurse observes a new irregular heart rhythm and
should perform which assessment at this time?
Check for a pulse deficit.
Palpate the apical impulse.
Inspect jugular vein pulse.
Examine for a carotid bruit. - Correct answer- Check for a pulse deficit.
A client with a past history of atrial fibrillation may return to that rhythm. Any signs of
atrial fibrillation, such as sudden onset shortness of breath, requires further
investigation. The nurse should assess this client for a pulse deficit because this
condition occurs with atrial fibrillation.
Which client should be further assessed for an ectopic pregnancy?
A 24-year-old with shoulder and lower abdominal quadrant pain.
A 33-year-old with intermittent lower abdominal cramping.
A 20-year-old with fever and right lower abdominal colic.
A 40-year-old with jaundice and right lower abdominal pain. - Correct answer- A 24-year-
old with shoulder and lower abdominal quadrant pain.
A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed
for an ectopic pregnancy. The pain can also be referred to the shoulder and may be
associated with vaginal bleeding.
, Which dietary assessment finding is most important for the nurse to address when
caring for a client with diabetic nephropathy?
Drinks a six pack of beer every day.
Enjoys a hamburger once a month.
Eats fortified breakfast cereal daily.
Consumes beans and rice every day. - Correct answer- Drinks a six pack of beer every
day.
Drinking six beers every day is the dietary assessment finding most important for the
nurse to address when caring for a client with diabetic nephropathy. The usual can of
beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more
than 12 ounces of beer per day because beer contains carbohydrates that can create
unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy
is exacerbated by poor blood glucose control.
Which assessment finding is of greatest concern to the nurse who is caring for a client
with stomatitis?
Cough brought on by swallowing.
Sore throat caused by speaking.
Painful and dry oral cavity.
Unintended weight loss. - Correct answer- Cough brought on by swallowing.
A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular
concern in a client with stomatitis. Dysphagia can cause numerous problems, including
airway obstruction, and should be reported to the healthcare provider immediately.
The nurse is teaching a client diagnosed with peripheral arterial disease. Which
genitourinary system complication should the nurse include in the teaching?
Altered sexual response.
, Sterility.
Urinary incontinence.
Decreased pelvic muscle tone. - Correct answer- Altered sexual response.
Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing
of the arteries and reduced blood flow to the extremities. PAD is known to alter the
blood flow to the male's penis and is associated with erectile dysfunction in men.
A 40-year-old female client has a history of smoking. Which finding should the nurse
identify as a risk factor for myocardial infarction?
Oral contraceptives.
Senile osteopenia.
Levothyroxine therapy.
Pernicious anemia. - Correct answer- Oral contraceptives.
Women older than 35 years old who smoke and take oral contraceptives have an
increased risk of myocardial infarction or stroke.
A client has been told that there is cataract formation over both eyes. Which finding
should the nurse expect when assessing the client?
Decreased color perception.
Presence of floaters.
Loss of central vision.
Reduced peripheral vision. - Correct answer- Decreased color perception.
Decreased color perception occurs with cataract formation. Cataract formation is also
associated with blurred vision and a global loss of vision so gradual that the client may
not be aware of it.