Nokea
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
- A. Bladder control
- B. Cognitive perception
- C. Respiratory system
- D. Sensory functions
Correct Answer: C
Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
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A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
- A. I can scratch with a coat hanger
- B. I should feel my fingers for warmth
- C. I will keep the cast clean and dry
- D. I will return to have the cast removed
Correct Answer: A
Rationale: Nothing should be placed under the cast to use for scratching, as this can cause skin damage or infection. The other statements show a good understanding of cast care instructions.
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment is most important?
- A. Ability to chew and swallow without aspiration
- B. Eating 75% of meals and between-meal snacks
- C. Intake greater than output for 3 days
- D. Weight gain of 3 pounds in 1 month
Correct Answer: D
Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty is necessary for an intact airway. Since the question does not include what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching? (Select all that apply.)
- A. Acyclovir (Zovirax)
- B. Carbamazepine (Tegretol)
- C. Famciclovir (Famvir)
- D. Prednisone (Deltasone)
- E. Valacyclovir (Valtrex)
Correct Answer: A,C,D,E
Rationale: Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
- A. MG is an autoimmune problem in which nerves do not cause muscles to contract
- B. MG is an inherited destruction of peripheral nerve endings and junctions
- C. MG is contact-induced paralysis of specific cranial nerves
- D. MG is a viral infection of the dorsal root of sensory nerve fibers
Correct Answer: A
Rationale: MG is an autoimmune disorder in which nerve fibers are damaged, and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.
A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
- A. Anxiety
- B. Low fluid volume
- C. Inadequate airway
- D. Potential for skin breakdown
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.