which of the following conditions has a severe complication of respiratory failure
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Nursing Elites

NCLEX-PN

Nclex Questions Management of Care

1. Which of the following conditions has a severe complication of respiratory failure?

Correct answer: B

Rationale: Guillain-Barr� syndrome is characterized by a severe complication of respiratory failure due to the involvement of the peripheral nerves that control breathing. While Bell's palsy, trigeminal neuralgia, and tetanus are also conditions affecting peripheral nerves, they do not typically lead to respiratory failure like Guillain-Barr� syndrome. Bell's palsy causes facial muscle weakness, trigeminal neuralgia results in severe facial pain, and tetanus leads to muscle stiffness and spasms, but none of these conditions directly involve respiratory failure.

2. In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

Correct answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse needs to consider various factors. Diabetic signs and symptoms, nutritional status, and availability of insulin are crucial aspects to assess for appropriate management during a crisis. However, bleeding problems are not directly related to diabetes or insulin therapy. Therefore, assessing for bleeding problems is not a priority in this context. Choice C, bleeding problems, is the correct answer as it is not typically associated with diabetes, unlike the other options provided.

3. Which of these would be an appropriate meal for a client with Celiac disease?

Correct answer: C

Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.

4. A small amount of bubbling is seen in the water seal of a pleural drainage system when a client coughs. What should the nurse do?

Correct answer: A

Rationale: A small amount of bubbling is a normal finding in the water seal of a pleural drainage system when a client coughs. It is only a problem to find continuous, excessive bubbling in the water seal, which indicates a leak. Checking the system for leaks would be appropriate if there is continuous, excessive bubbling. Clamping the chest tube or changing the drainage system is not necessary in response to a small amount of bubbling during a cough, as this is considered a normal finding.

5. A 20-year-old male client had a diving accident with subsequent paraplegia. He says to the nurse, "No woman will ever want to marry me now."? Which of the following responses by the nurse is most therapeutic?

Correct answer: D

Rationale: The correct response is 'Tell me more about your feelings on this issue.' This answer is the most therapeutic as it encourages the client to express his emotions and concerns, fostering a supportive and open dialogue between the client and the nurse. Option A may come across as dismissive and does not directly address the client's emotional state. Option B, while positive, oversimplifies the client's complex feelings. Option C focuses only on physical appearance, missing the opportunity to delve deeper into the client's emotional well-being. Therefore, the most therapeutic response is to encourage further discussion about the client's feelings.

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