A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

A client who has Guillain-Barré syndrome

A client who has systemic sclerosis

A client who has amyotrophic lateral sclerosis (ALS)

A client who has a lumbosacral spinal tumor

Answer and Explanation

The Correct Answer is D

Choice A reason:

A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.

Choice B reason:

A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.

Choice C reason:

A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.

Choice D reason:

A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.

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Free Nursing Study Resources

Correct Answer is ["0.2"]

Explanation

Step 1: Determine the concentration of morphine sulfate available. = 10 mg/mL

Step 2: Determine the dose of morphine sulfate to be administered. = 2 mg

Step 3: Calculate the volume to be administered using the formula: Volume to be administered = Dose ÷ Concentration

Step 4: Perform the division. Calculation: 2 mg ÷ 10 mg/mL = 0.2 mL

Step 5: Round the answer to the nearest tenth if necessary. = 0.2 mL (no rounding needed)

The nurse should administer 0.2 mL per dose.

A. Botulism is acquired through direct contact with an infected person. B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed. C. Botulism can produce paralysis within 12 to 72 hours following exposure. D. Vomiting and diarrhea are expected findings following exposure. E. Botulism is a toxin found in castor beans.

Correct Answer is ["C","D"]

Explanation

Choice A reason: Botulism is Acquired Through Direct Contact with an Infected Person

Botulism is not acquired through direct contact with an infected person. It is caused by a toxin produced by the bacterium Clostridium botulinum. The most common forms of botulism are foodborne, wound, and infant botulism. Foodborne botulism occurs when a person ingests food containing the toxin, while wound botulism occurs when the bacteria infect a wound and produce the toxin. Infant botulism occurs when infants ingest spores of the bacteria, which then grow and produce the toxin in their intestines.

Choice B reason: Notify the Centers for Disease Control and Prevention (CDC) When More Than Three Cases Are Confirmed

While notifying the CDC is crucial in the event of a botulism outbreak, the specific threshold for notification can vary. Generally, any suspected case of botulism should be reported to public health authorities immediately due to the severity of the disease and the potential for outbreaks. The CDC provides guidelines for reporting and managing botulism cases.

Choice C reason: Botulism Can Produce Paralysis Within 12 to 72 Hours Following Exposure

Botulism can indeed produce paralysis within 12 to 72 hours following exposure. The toxin affects the nervous system, leading to muscle paralysis. Early symptoms include weakness, dizziness, and dry mouth, followed by more severe symptoms such as blurred vision, difficulty swallowing, and muscle weakness. If left untreated, botulism can lead to respiratory failure and death.

Choice D reason: Vomiting and Diarrhea Are Expected Findings Following Exposure

Vomiting and diarrhea may occur early, especially in foodborne or inhalational exposures, before neurologic signs appear

Choice E reason: Botulism is a Toxin Found in Castor Beans

Botulism is not a toxin found in castor beans. The toxin found in castor beans is ricin, which is a different type of bioterrorism agent. Botulism is caused by the botulinum toxin produced by Clostridium botulinum bacteria.

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A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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