Nokea
The nurse caring for a client with Guillain-Barr?© syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
- A. Ask occupational therapy to help the client with activities of daily living
- B. Communicate with physical therapy for a consult
- C. Provide the client with information on support groups
- D. Refer the client to a medical social worker or chaplain
- E. Work with speech therapy to design a high-protein diet
Correct Answer: A,B,E
Rationale: Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy for nutritional support. While support groups, social work, or chaplain referrals may be needed, they do not directly help with mobility.
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A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
- A. Ask the client to explain his feelings related to this disorder
- B. Ask how dental hygiene is related to overall health
- C. Tell the client that he will become malnourished in time
- D. Inform the client about dental care options
Correct Answer: A
Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
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.
An older client is hospitalized with Guillain-Barr?© syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
- A. Assess the client's oxygen saturation
- B. Check the medication list for interactions
- C. Place the client on a bed alarm
- D. Put the client on safety precautions
Correct Answer: A
Rationale: In an older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate but only after this assessment occurs.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
- A. Do not eat a full meal for 45 minutes after taking the drug
- B. Seek immediate care if you develop trouble swallowing
- C. Take this drug on an empty stomach for best absorption
- D. The dose may change frequently depending on symptoms
- E. Your urine may turn a reddish-orange color while on this drug
Correct Answer: A,B,D
Rationale: Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not necessary, and the client's urine will not turn reddish-orange.
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.