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A patient has been diagnosed with Guillain-Barre Syndrome. Which of the following statements is the most applicable when discussing the impairments with Guillain-Barre Syndrome with the patient?
- A. Guillain-Barre Syndrome improves in almost all cases within 5 years.
- B. Guillain-Barre Syndrome causes limited sensation in the abdominal region.
- C. Guillain-Barre Syndrome causes muscle weakness in the legs.
- D. Guillain-Barre Syndrome affects breathing in severe cases.
Correct Answer: C
Rationale: The correct statement is that Guillain-Barre Syndrome causes muscle weakness in the legs. This muscle weakness typically starts in the legs and can progress to the upper body. Choice A is incorrect as while most cases do improve, the recovery time can vary. Choice B is incorrect as Guillain-Barre Syndrome primarily affects muscle weakness rather than sensation. Choice D is incorrect as severe cases of Guillain-Barre Syndrome can lead to respiratory muscle weakness, impacting breathing.
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A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?
- A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
- B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
- C. Test the sensation of the facial muscles and sensation of the back of the tongue.
- D. Test the sensation of the facial muscles and sensation of the front of the tongue.
Correct Answer: B
Rationale: The facial nerve (VII) is responsible for motor function to the face and sensory function to the anterior two-thirds of the tongue. Therefore, to appropriately test the function of cranial nerve VII, the most appropriate testing procedures involve assessing the taste sensation over the front of the tongue (sensory) and activation of the facial muscles (motor). Option B, 'Test the taste sensation over the front of the tongue and activation of the facial muscles,' is the correct answer. Choices A, C, and D are incorrect because they do not involve the correct combination of sensory testing over the front of the tongue and motor activation of the facial muscles, which are key functions associated with cranial nerve VII.
Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring
- B. grunting
- C. seesaw breathing
- D. quivering lips
Correct Answer: D
Rationale: Signs of impaired breathing in infants and children typically include nasal flaring, grunting, and seesaw breathing. Nasal flaring is the widening of the nostrils during breathing to help with air intake, grunting is a sound made during expiration to keep the airway open, and seesaw breathing is an abnormal pattern where the chest moves in while the abdomen moves out. Quivering lips are not a typical sign of impaired breathing in infants and children, making it the correct answer. Nasal flaring, grunting, and seesaw breathing are all signs indicating the need for immediate medical attention due to potential respiratory distress.
Which of the following is likely to increase the risk of sexually transmitted disease?
- A. alcohol use
- B. certain types of sexual practices
- C. oral contraception use
- D. all of the above
Correct Answer: D
Rationale: All of the above factors are likely to increase the risk of sexually transmitted diseases (STDs). Alcohol use can impair judgment, leading to risky sexual behavior. Certain types of sexual practices, especially unprotected sex or multiple partners, increase the likelihood of contracting STDs. While oral contraception use does not directly increase the risk of STDs, it does not protect against them either. Therefore, all the choices (alcohol use, certain types of sexual practices, and oral contraception use) can contribute to an increased risk of contracting STDs.
A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min via nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?
- A. COPD clients are stimulated to breathe by hypoxia.
- B. COPD clients depend on a low carbon dioxide level.
- C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen.
- D. COPD clients thrive on a high oxygen level.
Correct Answer: A
Rationale: In clients with COPD and chronic respiratory acidosis, they are compensating for low oxygen and high carbon dioxide levels. Hypoxia acts as the main stimulus to breathe in individuals with chronic hypercapnia. When oxygen is administered, it can decrease the respiratory drive by eliminating the hypoxic drive and reducing the stimulus to breathe. Therefore, delivering oxygen at 1 L/min via nasal cannula helps prevent respiratory depression by maintaining the hypoxic drive to breathe. The other options are incorrect: COPD clients do not depend on a low carbon dioxide level as they are chronically hypercapnic, they do not retain hydrogen ions with high oxygen doses, and they do not thrive on a high oxygen level.
What is the most effective strategy to assist a client in recognizing and using personal strength?
- A. Encouraging the client's self-identification of strengths.
- B. Promoting the client's active external thinking.
- C. Listening to the client and providing advice as needed.
- D. Assisting the client in maintaining an external locus of control.
Correct Answer: A
Rationale: Encouraging the client to identify their own strengths is empowering and helps build self-awareness and self-confidence. This strategy promotes autonomy and self-efficacy, enabling the client to recognize and utilize their personal strengths effectively. Option B, promoting the client's active external thinking, is vague and not directly related to recognizing personal strengths. Option C, listening to the client and providing advice as needed, focuses more on the nurse's role rather than empowering the client to recognize their strengths independently. Option D, assisting the client in maintaining an external locus of control, goes against the goal of helping the client recognize and utilize their internal strengths.