Nokea
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.
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A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
- A. Avoid others who are ill
- B. Check blood sugars four times a day
- C. Use two forms of contraception
- D. Wear properly fitting socks and shoes
Correct Answer: A
Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. While it is important to avoid injury, this is not specific to corticosteroid use.
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assessing the client's gag reflex
- B. Cutting foods up into small bites
- C. Monitoring potassium levels
- D. Weighing the client daily
- E. Thickening liquids to prevent aspiration
Correct Answer: B,D
Rationale: Cutting food up into smaller bites makes it easier for the client to chew and swallow. The UAP can weigh the client daily to monitor nutritional status. Assessing the gag reflex and monitoring potassium levels are tasks that require nursing judgment and cannot be delegated to UAP. Thickening liquids is typically a nursing or dietary intervention, not a UAP task.
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
- A. Giving antibiotics prior to treatments
- B. Monitoring the client's vital signs
- C. Performing appropriate hand hygiene
- D. Placing the client in protective isolation
Correct Answer: C
Rationale: Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
- A. Delayed afferent nerve impulses
- B. Delayed efferent nerve impulses
- C. Desynthesis in upper extremities
- D. Slows nerve impulse transmission
Correct Answer: D
Rationale: Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000 mm3, magnesium 0.8 mg/dL, and sodium 138 mEq/L. What action by the nurse is best?
- A. Advise the client to restrict fluids
- B. Assess the client for signs of infection
- C. Have the client add table salt to food
- D. Instruct the client on a magnesium supplement
Correct Answer: D
Rationale: Iron and magnesium deficiencies can exacerbate symptoms of restless leg syndrome. The client's magnesium level is low, and the client should be advised to add a magnesium supplement. The other actions are not needed based on the laboratory results.