Page 2054 - Saunders Comprehensive Review For NCLEX-RN

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718. A client with Guillain-Barré syndrome has ascending paralysis and is
intubated and receiving mechanical ventilation. Which strategy should the
nurse incorporate in the plan of care to help the client cope with this illness?
1. Giving client full control over care decisions and restricting
visitors
2. Providing positive feedback and encouraging active range of
motion
3. Providing information, giving positive feedback, and encouraging
relaxation
4. Providing intravenously administered sedatives, reducing
distractions, and limiting visitors
719. A client has a neurological deficit involving the limbic system. On
assessment, which finding is specific to this type of deficit?
1. Is disoriented to person, place, and time.
2. Affect is flat, with periods of emotional lability.
3. Cannot recall what was eaten for breakfast today.
4. Demonstrates inability to add and subtract; does not know who is
the president of the United States.
720. The nurse is instituting seizure precautions for a client who is being admitted
from the emergency department. Which measures should the nurse include
in planning for the client’s safety? Select all that apply.
1. Padding the side rails of the bed.

2. Placing an airway at the bedside.

3. Placing the bed in the high position.

4. Putting a padded tongue blade at the head of the bed.

5. Placing oxygen and suction equipment at the bedside.

6. Flushing the intravenous catheter to ensure that the site is
patent.
721. The nurse is evaluating the status of a client who had a craniotomy 3 days
ago. Which assessment finding would indicate that the client is developing
meningitis as a complication of surgery?
1. A negative Kernig’s sign
2. Absence of nuchal rigidity
3. A positive Brudzinski’s sign
4. A Glasgow Coma Scale score of 15
722. The nurse has completed discharge instructions for a client with application
of a halo device who sustained a cervical spinal cord injury. Which statement
indicates that the client needs further clarification of the instructions?
1. “I will use a straw for drinking.”
2. “I will drive only during the daytime.”
3. “I will be careful because the device alters balance.”
4. I will wash the skin daily under the lamb’s wool liner of the vest.”
723. The nurse is admitting a client with Guillain-Barré syndrome to the nursing

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