Question 1
Regular
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
Correct!
Incorrect
The correct answer is: C
Rationale
The respiratory system takes priority. Given that Guillain-Barr syndrome can lead to rapid respiratory muscle weakness and failure, assessing respiratory function is crucial for ensuring adequate ventilation and oxygenation for the client.
A: Bladder control. While important, bladder control does not present an immediate life-threatening risk like respiratory failure associated with GBS.
B: Cognitive perception. Cognitive function is significant, but the potential for respiratory compromise requires more urgent assessment to prevent critical complications.
D: Sensory functions. Sensory changes are relevant in GBS, yet they do not pose an immediate threat to survival, making them a lower priority than respiratory assessment.
Correct Answer: C
Rationale: The respiratory system takes priority. Given that Guillain-Barr syndrome can lead to rapid respiratory muscle weakness and failure, assessing respiratory function is crucial for ensuring adequate ventilation and oxygenation for the client.
A: Bladder control. While important, bladder control does not present an immediate life-threatening risk like respiratory failure associated with GBS.
B: Cognitive perception. Cognitive function is significant, but the potential for respiratory compromise requires more urgent assessment to prevent critical complications.
D: Sensory functions. Sensory changes are relevant in GBS, yet they do not pose an immediate threat to survival, making them a lower priority than respiratory assessment.
Question 2
Regular
The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
Correct!
Incorrect
The correct answer is: D
Rationale
Segmental demyelination slows nerve impulse transmission. This occurs because the loss of myelin sheaths around the nerves impairs the speed and efficiency of electrical signal conduction, leading to muscle weakness and sensory changes.
A: Delayed afferent nerve impulses. Afferent impulses relate to sensory signals; while demyelination affects these, the primary concern is the overall slowing of nerve conduction rather than solely afferent pathways.
B: Delayed efferent nerve impulses. Efferent impulses are responsible for motor function; however, the specific impact of segmental demyelination is more accurately described as a general slowing of nerve impulse transmission.
C: Desynthesis in upper extremities. This option misrepresents the effects of Guillian-Barr syndrome; segmental demyelination does not lead to desynthesis, but rather to impaired nerve signal transmission affecting movement and sensation.
Correct Answer: D
Rationale: Segmental demyelination slows nerve impulse transmission. This occurs because the loss of myelin sheaths around the nerves impairs the speed and efficiency of electrical signal conduction, leading to muscle weakness and sensory changes.
A: Delayed afferent nerve impulses. Afferent impulses relate to sensory signals; while demyelination affects these, the primary concern is the overall slowing of nerve conduction rather than solely afferent pathways.
B: Delayed efferent nerve impulses. Efferent impulses are responsible for motor function; however, the specific impact of segmental demyelination is more accurately described as a general slowing of nerve impulse transmission.
C: Desynthesis in upper extremities. This option misrepresents the effects of Guillian-Barr syndrome; segmental demyelination does not lead to desynthesis, but rather to impaired nerve signal transmission affecting movement and sensation.
Question 3
Regular
A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
Correct!
Incorrect
The correct answer is: C
Rationale
Inadequate airway. Guillain-Barr syndrome can lead to respiratory muscle weakness, making airway management a critical concern. Prioritizing airway interventions ensures that the client maintains adequate ventilation and oxygenation, preventing life-threatening complications.
A: Anxiety. While anxiety may arise due to hospitalization and health concerns, it does not pose an immediate threat to life, making it a lower priority than airway management.
B: Low fluid volume. Although hydration is important, it is not as urgent as addressing airway issues, especially given the potential for respiratory failure in Guillain-Barr syndrome patients.
D: Potential for skin breakdown. Skin integrity is significant, yet it does not require immediate intervention compared to the critical need for maintaining an adequate airway in this situation.
Correct Answer: C
Rationale: Inadequate airway. Guillain-Barr syndrome can lead to respiratory muscle weakness, making airway management a critical concern. Prioritizing airway interventions ensures that the client maintains adequate ventilation and oxygenation, preventing life-threatening complications.
A: Anxiety. While anxiety may arise due to hospitalization and health concerns, it does not pose an immediate threat to life, making it a lower priority than airway management.
B: Low fluid volume. Although hydration is important, it is not as urgent as addressing airway issues, especially given the potential for respiratory failure in Guillain-Barr syndrome patients.
D: Potential for skin breakdown. Skin integrity is significant, yet it does not require immediate intervention compared to the critical need for maintaining an adequate airway in this situation.
Question 4
Regular
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
Correct!
Incorrect
The correct answer is: C
Rationale
Obtaining atropine sulfate is the most important action by the nurse when preparing a client for a Tensilon test. This medication serves as an antidote for potential adverse effects of edrophonium chloride, particularly respiratory complications.
A: Administering anxiolytics does not directly address the critical need for emergency intervention during the Tensilon test, which focuses on potential cholinergic crisis management.
B: Administering a ventilator is not a proactive measure; it is a reactive intervention that does not prepare the client for the test itself effectively.
D: Sedating the client may obscure the test results and mask symptoms, preventing accurate assessment of muscle strength and response to edrophonium chloride.
Correct Answer: C
Rationale: Obtaining atropine sulfate is the most important action by the nurse when preparing a client for a Tensilon test. This medication serves as an antidote for potential adverse effects of edrophonium chloride, particularly respiratory complications.
A: Administering anxiolytics does not directly address the critical need for emergency intervention during the Tensilon test, which focuses on potential cholinergic crisis management.
B: Administering a ventilator is not a proactive measure; it is a reactive intervention that does not prepare the client for the test itself effectively.
D: Sedating the client may obscure the test results and mask symptoms, preventing accurate assessment of muscle strength and response to edrophonium chloride.
Question 5
Regular
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Avoid others who are ill. Long-term corticosteroid therapy suppresses the immune system, increasing susceptibility to infections. Teaching clients to avoid contact with sick individuals reduces their risk of illness significantly.
B: Check blood sugars four times a day. Routine blood sugar monitoring is not universally necessary for all patients on corticosteroids unless they have diabetes or exhibit hyperglycemia symptoms.
C: Use two forms of contraception. While corticosteroids can affect hormonal balance, they do not typically necessitate dual contraceptive methods unless specific medications that interact are prescribed alongside them.
D: Wear properly fitting socks and shoes. Although this is important for general foot care, it does not specifically address the unique immunosuppressive risks associated with long-term corticosteroid use in myasthenia gravis patients.
Correct Answer: A
Rationale: A: Avoid others who are ill. Long-term corticosteroid therapy suppresses the immune system, increasing susceptibility to infections. Teaching clients to avoid contact with sick individuals reduces their risk of illness significantly.
B: Check blood sugars four times a day. Routine blood sugar monitoring is not universally necessary for all patients on corticosteroids unless they have diabetes or exhibit hyperglycemia symptoms.
C: Use two forms of contraception. While corticosteroids can affect hormonal balance, they do not typically necessitate dual contraceptive methods unless specific medications that interact are prescribed alongside them.
D: Wear properly fitting socks and shoes. Although this is important for general foot care, it does not specifically address the unique immunosuppressive risks associated with long-term corticosteroid use in myasthenia gravis patients.
Question 6
Regular
A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment is most important?
Correct!
Incorrect
The correct answer is: D
Rationale
Weight gain of 3 pounds in 1 month is the most important assessment for a client with myasthenia gravis and inadequate nutrition. This reflects a positive trend in nutritional intake and indicates effective management of the condition, suggesting that the client is receiving enough calories to sustain health and prevent further complications.
A: Ability to chew and swallow without aspiration does not directly indicate nutritional status, as a patient may manage these functions yet still experience inadequate nutrition due to insufficient intake or absorption.
B: Eating 75% of meals and between-meal snacks provides a measure of food intake but does not guarantee adequate nutrition, as quality and caloric density of food are also critical factors.
C: Intake greater than output for 3 days may suggest positive nutritional balance but lacks context regarding weight changes and overall health, making it less reliable than actual weight gain.
Correct Answer: D
Rationale: Weight gain of 3 pounds in 1 month is the most important assessment for a client with myasthenia gravis and inadequate nutrition. This reflects a positive trend in nutritional intake and indicates effective management of the condition, suggesting that the client is receiving enough calories to sustain health and prevent further complications.
A: Ability to chew and swallow without aspiration does not directly indicate nutritional status, as a patient may manage these functions yet still experience inadequate nutrition due to insufficient intake or absorption.
B: Eating 75% of meals and between-meal snacks provides a measure of food intake but does not guarantee adequate nutrition, as quality and caloric density of food are also critical factors.
C: Intake greater than output for 3 days may suggest positive nutritional balance but lacks context regarding weight changes and overall health, making it less reliable than actual weight gain.
Question 7
Regular
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?
Correct!
Incorrect
The correct answer is: A
Rationale
I can scratch with a coat hanger. This statement shows a poor understanding of discharge instructions, as scratching under the cast can cause skin irritation, infection, or damage to the healing area. Proper cast care emphasizes keeping the cast intact and avoiding any foreign objects that could compromise recovery.
B: I should feel my fingers for warmth. This demonstrates awareness of circulation and nerve function, indicating the client understands the importance of monitoring for any signs of complications in the affected area.
C: I will keep the cast clean and dry. This reflects a proper understanding of cast care, highlighting the necessity of maintaining cleanliness and dryness to promote healing and prevent complications.
D: I will return to have the cast removed. This shows an understanding of the treatment plan, indicating the client recognizes the importance of follow-up care to ensure proper recovery and cast management.
Correct Answer: A
Rationale: I can scratch with a coat hanger. This statement shows a poor understanding of discharge instructions, as scratching under the cast can cause skin irritation, infection, or damage to the healing area. Proper cast care emphasizes keeping the cast intact and avoiding any foreign objects that could compromise recovery.
B: I should feel my fingers for warmth. This demonstrates awareness of circulation and nerve function, indicating the client understands the importance of monitoring for any signs of complications in the affected area.
C: I will keep the cast clean and dry. This reflects a proper understanding of cast care, highlighting the necessity of maintaining cleanliness and dryness to promote healing and prevent complications.
D: I will return to have the cast removed. This shows an understanding of the treatment plan, indicating the client recognizes the importance of follow-up care to ensure proper recovery and cast management.
Question 8
Regular
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?
Correct!
Incorrect
The correct answer is: D
Rationale
Instruct the client on a magnesium supplement. Restless leg syndrome is often linked to magnesium deficiency, and the laboratory result shows a low magnesium level, indicating that supplementation could alleviate symptoms effectively.
A: Advise the client to restrict fluids. Fluid restriction does not address the underlying issue of magnesium deficiency associated with restless leg syndrome, making it an irrelevant intervention for this client.
B: Assess the client for signs of infection. The laboratory results do not indicate any infection risk, as the white blood cell count is within normal limits, rendering this assessment unnecessary.
C: Have the client add table salt to food. Sodium levels are normal, and increasing salt intake does not correlate with improving symptoms of restless leg syndrome, which is related to magnesium levels.
Correct Answer: D
Rationale: Instruct the client on a magnesium supplement. Restless leg syndrome is often linked to magnesium deficiency, and the laboratory result shows a low magnesium level, indicating that supplementation could alleviate symptoms effectively.
A: Advise the client to restrict fluids. Fluid restriction does not address the underlying issue of magnesium deficiency associated with restless leg syndrome, making it an irrelevant intervention for this client.
B: Assess the client for signs of infection. The laboratory results do not indicate any infection risk, as the white blood cell count is within normal limits, rendering this assessment unnecessary.
C: Have the client add table salt to food. Sodium levels are normal, and increasing salt intake does not correlate with improving symptoms of restless leg syndrome, which is related to magnesium levels.
Question 9
Regular
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
Correct!
Incorrect
The correct answer is: C
Rationale
C: Do not use harsh chemicals on your face. This instruction is paramount as the percutaneous stereotactic rhizotomy procedure can cause sensitive skin and increased vulnerability to irritants, requiring gentle care during recovery.
A: Avoid having teeth pulled for 1 year. While dental procedures may be affected, this guideline is overly cautious and not specifically relevant to the recovery from this surgery.
B: Avoid heavy lifting for 6 months. This restriction may not apply directly following a rhizotomy, as the procedure typically focuses on facial pain management rather than physical strain concerns.
D: Inform your dentist of this procedure. While communication is important, this instruction does not directly impact the immediate recovery or care needed after a percutaneous stereotactic rhizotomy.
Correct Answer: C
Rationale: C: Do not use harsh chemicals on your face. This instruction is paramount as the percutaneous stereotactic rhizotomy procedure can cause sensitive skin and increased vulnerability to irritants, requiring gentle care during recovery.
A: Avoid having teeth pulled for 1 year. While dental procedures may be affected, this guideline is overly cautious and not specifically relevant to the recovery from this surgery.
B: Avoid heavy lifting for 6 months. This restriction may not apply directly following a rhizotomy, as the procedure typically focuses on facial pain management rather than physical strain concerns.
D: Inform your dentist of this procedure. While communication is important, this instruction does not directly impact the immediate recovery or care needed after a percutaneous stereotactic rhizotomy.
Question 10
Regular
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
Correct!
Incorrect
The correct answer is: A
Rationale
A: Asking the client to explain his feelings related to trigeminal neuralgia allows for open communication, fostering a therapeutic relationship. This approach helps the nurse understand the underlying emotional factors influencing the client’s behaviors, promoting tailored support for his specific needs.
B: Inquiring about dental hygiene's relation to overall health may raise awareness, but it lacks immediate emotional support. This option does not address the client’s psychological state, which is crucial for effective care.
C: Telling the client that he will become malnourished in time could instill fear or anxiety. This approach may not motivate change and neglects the importance of addressing the client’s feelings and concerns directly.
D: Informing the client about dental care options may provide useful information, yet it fails to engage with his emotional struggles. Addressing feelings first is essential for encouraging proactive health behaviors.
Correct Answer: A
Rationale: A: Asking the client to explain his feelings related to trigeminal neuralgia allows for open communication, fostering a therapeutic relationship. This approach helps the nurse understand the underlying emotional factors influencing the client’s behaviors, promoting tailored support for his specific needs.
B: Inquiring about dental hygiene's relation to overall health may raise awareness, but it lacks immediate emotional support. This option does not address the client’s psychological state, which is crucial for effective care.
C: Telling the client that he will become malnourished in time could instill fear or anxiety. This approach may not motivate change and neglects the importance of addressing the client’s feelings and concerns directly.
D: Informing the client about dental care options may provide useful information, yet it fails to engage with his emotional struggles. Addressing feelings first is essential for encouraging proactive health behaviors.
Question 11
Regular
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
Correct!
Incorrect
The correct answer is: C
Rationale
Performing appropriate hand hygiene. Maintaining proper hand hygiene is crucial in preventing infection during plasmapheresis, as it significantly reduces the transmission of pathogens and protects the client’s vulnerable immune system during treatment.
A: Giving antibiotics prior to treatments. While antibiotics can prevent infection, they do not address the immediate risk associated with the procedure itself and may contribute to antibiotic resistance.
B: Monitoring the client's vital signs. Monitoring vital signs is essential for assessing the client’s response but does not directly prevent infection during the plasmapheresis process itself.
D: Placing the client in protective isolation. Protective isolation may help reduce exposure to pathogens, but it is not a primary measure taken during plasmapheresis to prevent infection effectively.
Correct Answer: C
Rationale: Performing appropriate hand hygiene. Maintaining proper hand hygiene is crucial in preventing infection during plasmapheresis, as it significantly reduces the transmission of pathogens and protects the client’s vulnerable immune system during treatment.
A: Giving antibiotics prior to treatments. While antibiotics can prevent infection, they do not address the immediate risk associated with the procedure itself and may contribute to antibiotic resistance.
B: Monitoring the client's vital signs. Monitoring vital signs is essential for assessing the client’s response but does not directly prevent infection during the plasmapheresis process itself.
D: Placing the client in protective isolation. Protective isolation may help reduce exposure to pathogens, but it is not a primary measure taken during plasmapheresis to prevent infection effectively.
Question 12
Regular
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?
Correct!
Incorrect
The correct answer is: A
Rationale
Assess the client's oxygen saturation.
Restlessness and confusion in a hospitalized client with Guillain-Barré syndrome may indicate hypoxia or other respiratory issues, making it imperative to assess oxygen saturation to ensure the client’s safety and well-being.
B: Check the medication list for interactions. While medication interactions are important, they do not directly address the immediate symptoms of restlessness and confusion, which could be related to oxygen levels.
C: Place the client on a bed alarm. Although a bed alarm may prevent falls, it does not address the potential underlying cause of restlessness and confusion, which needs urgent assessment.
D: Put the client on safety precautions. Implementing safety measures is beneficial, but it does not resolve the immediate concern of assessing the client’s physiological status related to their symptoms.
Correct Answer: A
Rationale: Assess the client's oxygen saturation.
Restlessness and confusion in a hospitalized client with Guillain-Barré syndrome may indicate hypoxia or other respiratory issues, making it imperative to assess oxygen saturation to ensure the client’s safety and well-being.
B: Check the medication list for interactions. While medication interactions are important, they do not directly address the immediate symptoms of restlessness and confusion, which could be related to oxygen levels.
C: Place the client on a bed alarm. Although a bed alarm may prevent falls, it does not address the potential underlying cause of restlessness and confusion, which needs urgent assessment.
D: Put the client on safety precautions. Implementing safety measures is beneficial, but it does not resolve the immediate concern of assessing the client’s physiological status related to their symptoms.
Question 13
Regular
A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best?
Correct!
Incorrect
The correct answer is: A
Rationale
MG is an autoimmune problem in which nerves do not cause muscles to contract. This response accurately describes the underlying mechanism of myasthenia gravis, where the immune system mistakenly attacks acetylcholine receptors, leading to muscle weakness and fatigue.
B: MG is an inherited destruction of peripheral nerve endings and junctions. This description misrepresents MG as it is not inherited and involves an autoimmune attack rather than a genetic condition.
C: MG is contact-induced paralysis of specific cranial nerves. This explanation is misleading; myasthenia gravis does not involve paralysis from contact but rather results from an autoimmune process affecting muscle function.
D: MG is a viral infection of the dorsal root of sensory nerve fibers. This option incorrectly identifies MG as a viral infection, while it is primarily an autoimmune disorder affecting neuromuscular transmission.
Correct Answer: A
Rationale: MG is an autoimmune problem in which nerves do not cause muscles to contract. This response accurately describes the underlying mechanism of myasthenia gravis, where the immune system mistakenly attacks acetylcholine receptors, leading to muscle weakness and fatigue.
B: MG is an inherited destruction of peripheral nerve endings and junctions. This description misrepresents MG as it is not inherited and involves an autoimmune attack rather than a genetic condition.
C: MG is contact-induced paralysis of specific cranial nerves. This explanation is misleading; myasthenia gravis does not involve paralysis from contact but rather results from an autoimmune process affecting muscle function.
D: MG is a viral infection of the dorsal root of sensory nerve fibers. This option incorrectly identifies MG as a viral infection, while it is primarily an autoimmune disorder affecting neuromuscular transmission.
Question 14
Multiple Choice
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,B,D
Rationale
Do not eat a full meal for 45 minutes after taking the drug, seek immediate care if you develop trouble swallowing, and the dose may change frequently depending on symptoms.
A: Do not eat a full meal for 45 minutes after taking the drug. This guideline helps maximize the medication's effectiveness and absorption, ensuring optimal therapeutic action for managing myasthenia gravis symptoms.
C: Take this drug on an empty stomach for best absorption. While pyridostigmine may be absorbed better on an empty stomach, timing with meals can be adjusted to prevent gastrointestinal discomfort.
E: Your urine may turn a reddish-orange color while on this drug. This side effect is not typical for pyridostigmine, which does not commonly alter urine color, indicating it is not a relevant teaching point.
Correct Answer: A,B,D
Rationale: Do not eat a full meal for 45 minutes after taking the drug, seek immediate care if you develop trouble swallowing, and the dose may change frequently depending on symptoms.
A: Do not eat a full meal for 45 minutes after taking the drug. This guideline helps maximize the medication's effectiveness and absorption, ensuring optimal therapeutic action for managing myasthenia gravis symptoms.
C: Take this drug on an empty stomach for best absorption. While pyridostigmine may be absorbed better on an empty stomach, timing with meals can be adjusted to prevent gastrointestinal discomfort.
E: Your urine may turn a reddish-orange color while on this drug. This side effect is not typical for pyridostigmine, which does not commonly alter urine color, indicating it is not a relevant teaching point.
Question 15
Multiple Choice
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching? (Select all that apply.)
Correct!
Incorrect
The correct answer is: A,C,D,E
Rationale
Acyclovir (Zovirax), Famciclovir (Famvir), Prednisone (Deltasone), and Valacyclovir (Valtrex) are all relevant medications for managing Bell's palsy, addressing viral causes and reducing inflammation associated with the condition.
B: Carbamazepine (Tegretol) Primarily used for seizure disorders and neuropathic pain, Carbamazepine does not directly treat Bell's palsy, making it unsuitable for this specific condition management.
Correct Answer: A,C,D,E
Rationale: Acyclovir (Zovirax), Famciclovir (Famvir), Prednisone (Deltasone), and Valacyclovir (Valtrex) are all relevant medications for managing Bell's palsy, addressing viral causes and reducing inflammation associated with the condition.
B: Carbamazepine (Tegretol) Primarily used for seizure disorders and neuropathic pain, Carbamazepine does not directly treat Bell's palsy, making it unsuitable for this specific condition management.
Question 16
Multiple Choice
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.)
Correct!
Incorrect
The correct answer is: B,D
Rationale
B: Cutting foods up into small bites and D: Weighing the client daily are appropriate tasks for UAP, as they can help enhance the client's ability to eat safely and track weight for nutritional assessment.
A: Assessing the client's gag reflex requires clinical judgment and expertise, making it unsuitable for delegation to UAP who lack the necessary training.
C: Monitoring potassium levels involves understanding lab results and implications, which necessitates a licensed professional's competence to interpret changes accurately.
E: Thickening liquids to prevent aspiration entails knowledge of specific dietary modifications and potential implications, tasks that should be performed by licensed staff for safety reasons.
Correct Answer: B,D
Rationale: B: Cutting foods up into small bites and D: Weighing the client daily are appropriate tasks for UAP, as they can help enhance the client's ability to eat safely and track weight for nutritional assessment.
A: Assessing the client's gag reflex requires clinical judgment and expertise, making it unsuitable for delegation to UAP who lack the necessary training.
C: Monitoring potassium levels involves understanding lab results and implications, which necessitates a licensed professional's competence to interpret changes accurately.
E: Thickening liquids to prevent aspiration entails knowledge of specific dietary modifications and potential implications, tasks that should be performed by licensed staff for safety reasons.
Question 17
Multiple Choice
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.)
Correct!
Incorrect
The correct answer is: A,B,E
Rationale
The nurse should ask occupational therapy to assist with daily activities, communicate with physical therapy for mobility enhancement, and collaborate with speech therapy for a high-protein diet to support recovery.
A: Asking occupational therapy to help the client with activities of daily living directly addresses the decreased mobility by providing practical support and strategies for daily functioning.
B: Communicating with physical therapy for a consult is essential for tailored interventions that promote mobility, enhancing the client’s physical capabilities and independence during recovery.
C: Providing the client with information on support groups addresses emotional needs rather than directly improving mobility, which is the primary concern in the context of Guillain-Barré syndrome.
D: Referring the client to a medical social worker or chaplain focuses on psychosocial support, which, while important, does not target the immediate issue of decreased mobility effectively.
E: Working with speech therapy to design a high-protein diet supports nutritional needs, but it does not specifically address the mobility challenges faced by the client.
Correct Answer: A,B,E
Rationale: The nurse should ask occupational therapy to assist with daily activities, communicate with physical therapy for mobility enhancement, and collaborate with speech therapy for a high-protein diet to support recovery.
A: Asking occupational therapy to help the client with activities of daily living directly addresses the decreased mobility by providing practical support and strategies for daily functioning.
B: Communicating with physical therapy for a consult is essential for tailored interventions that promote mobility, enhancing the client’s physical capabilities and independence during recovery.
C: Providing the client with information on support groups addresses emotional needs rather than directly improving mobility, which is the primary concern in the context of Guillain-Barré syndrome.
D: Referring the client to a medical social worker or chaplain focuses on psychosocial support, which, while important, does not target the immediate issue of decreased mobility effectively.
E: Working with speech therapy to design a high-protein diet supports nutritional needs, but it does not specifically address the mobility challenges faced by the client.
Quiz Complete!
Care of Patients with Problems of the Peripheral Nervous System
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