Nokea
The nurse is caring for the client experiencing Guillain-Barré syndrome (GBS). It is most important for the nurse to monitor the client for which complication?
- A. Autonomic dysreflexia
- B. Septic emboli
- C. Cardiac dysrhythmias
- D. Respiratory failure
Correct Answer: D
Rationale: The client with SCI, not GBS, should be monitored for autonomic dysreflexia. The client who has bacterial meningitis should be monitored for septic emboli. Although the client with GBS should be monitored for cardiac dysrhythmias, it is most important to monitor for respiratory failure. It is most important for the nurse to monitor for respiratory failure. Ascending paralysis that occurs in GBS can affect the innervations of the muscles used in respiration, leading to respiratory failure.
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Which discharge teaching is essential for a client with a spinal cord injury to prevent respiratory complications?
- A. Perform deep breathing exercises daily.
- B. Avoid outdoor activities.
- C. Limit fluid intake to reduce secretions.
- D. Sleep in a prone position.
Correct Answer: A
Rationale: Deep breathing exercises help prevent atelectasis and pneumonia in clients with spinal cord injuries.
When the nursing team plans the care of a client with Guillain-Barré syndrome, which assessment finding most accurately determines whether the client is developing ineffective breathing?
- A. Respiratory rate is 24.
- B. Skin is flushed.
- C. Activity is decreased.
- D. Pulse oximetry reading is 82%.
Correct Answer: D
Rationale: A pulse oximetry reading of 82% indicates significant hypoxemia, suggesting ineffective breathing, which is a critical concern in Guillain-Barré syndrome due to potential respiratory muscle weakness.
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
The nurse reviews the chart of the client who had a T12 SCI 12 years ago and is receiving baclofen through an intrathecal infusion pump. Which chart information in the exhibit is most important for the nurse to discuss with the HCP?
- A. Assessment findings
- B. Orthostatic hypotension
- C. Laboratory test results
- D. Prescribed medications
Correct Answer: A
Rationale: Exaggerated spasticity, muscle rigidity, and tinnitus are adverse effects of baclofen (Lioresal) that the nurse should discuss with the HCP. The client had a minimal drop in BP from lying to standing and does not have orthostatic hypotension. The WBC and liver enzymes are WNL. The glucose is not significantly elevated and would not warrant notifying the HCP. All prescribed medications are appropriate for the client who has a T12 SCI.