A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority?
Respiratory system
Cognitive perception
Bladder control
The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what?
Slowed nerve impulse transmission
Paresthesia in upper extremities
Paralysis of affected muscles
A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
Inadequate airway
Low fluid volume
Anxiety
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
Obtaining atropine sulfate
Having a ventilator nearby
Administering anxiolytics
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Avoid large crowds and people who are ill.
Check blood sugars four times a day.
Use two forms of contraception.
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment finding indicates that the priority goal for this client problem has been met?
Weight gain of 3 pounds in 1 month
Intake greater than output 3 days in a row
Eating 75% of meals and between-meal snacks
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?
“I can scratch with a coat hanger.”
“I should feel my fingers for warmth.”
“I will keep the cast clean and dry.”
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best?
Instruct the client on a magnesium supplement.
Have the client add table salt to food.
Assess the client for signs of infection.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
“Do not use harsh chemicals on your face.”
. “Brush your teeth with a soft toothbrush.”
“Avoid having teeth pulled for 1 year.”
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best?
Ask the client to explain his feelings related to this disorder.
Explain how dental hygiene is related to overall health.
. Refer the client to a medical social worker for assessment.
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
Performing appropriate hand hygiene
Monitoring the client’s vital signs
Giving antibiotics prior to treatments
An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
Assess the client’s oxygen saturation
Check the medication list for interactions.
Place the client on a bed alarm.
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
“MG is an autoimmune problem in which nerves do not cause muscles to contract.”
MG is an inherited destruction of peripheral nerve endings and junctions.”
“MG consists of trauma-induced paralysis of specific cranial nerves.”
. A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
Do not eat a full meal for 45 minutes after taking the drug.”
“Seek immediate care if you develop trouble swallowing.”
“The dose may change frequently depending on symptoms.”
“Take this drug on an empty stomach for best absorption.”
“Your urine may turn a reddish-orange color while on this drug.”
A client has been diagnosed with Bell’s palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.)
. Acyclovir (Zovirax)
Famciclovir (Famvir)
Prednisone (Deltasone)
Valacyclovir (Valtrex)
Carbamazepine (Tegretol)
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.)
Cutting foods up into small bites
Thickening liquids prior to drinking
Assessing the client’s gag reflex
Monitoring prealbumin levels
Weighing the client daily
An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.)
Advising the client to have help getting up
. Consulting the provider about the drug
Placing the client on safety precautions
. Administering the medication as ordered
Cutting the dose of the drug in half
The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
Ask occupational therapy to help the client with activities of daily living.
Consult with the provider about a physical therapy consult.
Work with speech therapy to design a high-protein diet.
Provide the client with information on support groups.
Refer the client to a medical social worker or chaplain.
