NR-325 Adult Health II - Set 4 - Part 3

Correct Answer: Acknowledge her distress and discuss choosing a wig

Naming the loss as real comes first, and practical planning follows. Selecting a head covering before hair falls out lets her match color and style, which restores a measure of control. Option a is incorrect because minimizing the loss shuts down the conversation she just opened. Visible hair loss announces the diagnosis to everyone she meets, and dismissing that leaves her feeling unheard. Option c is incorrect because scalp cooling reduces hair loss with some regimens without guaranteeing anything. Promising a result the device cannot deliver sets her up for a second disappointment weeks from now. Option d is incorrect because postponing treatment trades a temporary cosmetic effect for tumor growth. Hair regrows within a few months of the last dose, so delay costs far more than it spares.

Correct Answer: Recline the chair and raise the legs

This is orthostatic hypotension, the mirror image of dysreflexia. Tipping the client back and elevating the legs returns pooled blood to the heart and clears the symptoms within moments. Option a is incorrect because raising the trunk further drops cerebral perfusion even more in a client who cannot constrict a single vessel below the lesion. Upright positioning is the dysreflexia answer. Option b is incorrect because a binder belongs on before the client goes up, as a preventive measure. Wrestling one into place during an episode delays the position change that fixes the problem. Option c is incorrect because fluids help over hours, not seconds, and a dizzy client sitting upright may not swallow safely. Hydration supports the plan but treats nothing at this moment.

Correct Answer: The shallow breathing and weak cough

Airway and breathing outrank every other finding. A fourth cervical lesion leaves barely any diaphragm reserve, so a weakening cough and shallow breaths signal impending respiratory failure and come first. Option a is incorrect because a full bladder matters and will be drained, yet it threatens nothing in the next few minutes. Circulation and breathing are ranked ahead of elimination in every priority framework. Option c is incorrect because this pressure is typical after sympathetic outflow is lost and is managed with fluids and vasopressors. Breathing still outranks it, since apnea kills faster than a soft pressure. Option d is incorrect because cold feet reflect poikilothermia and pooled blood in dilated vessels, an expected consequence of the injury. Warming measures are worthwhile but never the opening move.

Correct Answer: Steroids help the relapse but not this peripheral nerve disorder

Corticosteroids shorten a multiple sclerosis relapse but have no benefit in Guillain Barre syndrome and may worsen outcomes. Immune globulin or plasma exchange is used instead, chosen one at a time. Option a is incorrect because steroid therapy is standard only on the multiple sclerosis side. Offering methylprednisolone to a client with ascending peripheral weakness wastes time and adds hyperglycemia, mood swings and infection risk. Option b is incorrect because the two therapies are equally effective and are not stacked. Giving immune globulin soon after an exchange simply lets the next session strip the antibodies right back out. Option c is incorrect because immune globulin and plasma exchange are exactly what works here. Both remove or neutralize the circulating antibodies attacking peripheral myelin, and one of them is started early.

Correct Answer: Raise the head of the bed and give oxygen

Obstructed venous return from the head and upper chest threatens the airway, so sitting the client upright and adding oxygen come before anything else. Upper extremity lines are avoided while drainage is blocked. Option b is incorrect because fluid infused into an arm cannot drain past the obstruction and pools in already congested tissue. Access below the diaphragm is chosen when this syndrome is suspected. Option c is incorrect because the swelling comes from blocked venous outflow, not from local inflammation. Heat does nothing for a mechanical obstruction and delays the positioning and oxygen this client needs. Option d is incorrect because lying flat worsens engorgement of the head and neck and can tip a narrowed airway into stridor. Clients with this syndrome describe symptoms that peak when recumbent.

Correct Answer: "I will put on gloves before I garden and use insect repellent."

Gloves shield the hand from cuts and thorns, and repellent prevents insect bites. Both hazards break the skin of a limb whose reduced lymphatic drainage can no longer clear invading bacteria. Option a is incorrect because anything circling that wrist constricts lymph flow below it. A snug bracelet works exactly like a tight sleeve or watch band, and jewelry on that side is discouraged. Option b is incorrect because blade razors nick the skin and open a portal for bacteria. An electric razor is taught instead, since underarm shaving happens close to the disrupted lymphatic bed. Option d is incorrect because heat drives vasodilation and raises the volume of fluid the arm must move. Hot tubs, saunas, and heating pads are avoided on that side for the same reason.

Correct Answer: Stop the measurement and use the other arm

Cuff inflation compresses a limb whose lymphatic drainage was permanently reduced by axillary surgery, so the nurse halts the procedure immediately and directs staff to the unaffected arm before any teaching occurs. Option b is incorrect because recording a reading obtained from the at-risk limb accepts the very trauma the precaution exists to prevent. Delayed notification does nothing about compression that has already squeezed impaired lymphatic channels. Option c is incorrect because comfort is not the issue here. Even a cuff that feels loose still obstructs venous and lymphatic return, and asking about sensation leaves the prohibited measurement running on that side. Option d is incorrect because allowing the cycle to complete delivers the full compression the rule forbids. Safety comes before education, so the cuff comes off first and staff are corrected afterward.

Correct Answer: Each child of an affected parent has fifty percent risk

Huntington disease follows autosomal dominant inheritance, so every child of an affected parent carries a one in two chance regardless of sex. Formal counseling before and after testing is a required part of the process. Option a is incorrect because dominant inheritance with essentially complete penetrance leaves no room for skipped generations. Anyone who develops the illness had a parent who carried the same expanded gene. Option b is incorrect because the responsible gene sits on chromosome four rather than a sex chromosome. Daughters and sons face identical risk, and men and women develop the illness in equal numbers. Option c is incorrect because knowing a result no treatment can change carries heavy psychological weight. Structured counseling, psychological assessment and a waiting period protect the person before and after the test is done.

Correct Answer: "I will sit up straight away and loosen my clothes."

Sitting upright and loosening anything tight are the first two steps of the drill, and both work in seconds. The client then checks the catheter while someone takes the blood pressure. Option a is incorrect because lying flat removes the gravity that drains blood away from the head and lets the pressure climb higher. This is the opposite of what the client must do. Option c is incorrect because pushing on the abdomen delivers another painful signal below the injury and worsens the surge. Bladder emptying is done with a catheter, never with the hands. Option d is incorrect because waiting an hour with a systolic pressure in stroke range risks a brain bleed or a seizure. Every step of the drill happens immediately, not on a delay.

Correct Answer: Assisting with the scheduled turn every two hours

Repositioning on a set schedule is a standard task with a predictable outcome, so it fits assistive personnel. The nurse still inspects the skin and keeps responsibility for the turning plan. Option a is incorrect because client education sits squarely inside the nursing scope and cannot be handed off. Assistive personnel may reinforce a habit the nurse has taught, but they do not deliver the teaching. Option b is incorrect because digital stimulation is an invasive procedure that can set off a hypertensive crisis in this client. It requires nursing judgment, anesthetic lubricant and continuous blood pressure watching. Option d is incorrect because sacral sensation is part of the neurologic examination, and its findings decide how the injury is classified. Assessment of that kind never leaves the licensed nurse.