front 1 A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness? 1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors | back 1 3.Providing information, giving positive feedback, and encouraging relaxation |
front 2 The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray | back 2 4.Electrocardiographic monitoring electrodes and intubation tray |
front 3 The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the primary health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1.Multifocal seizures 2.Altered level of consciousness 3.Abrupt onset of a fever and headache 4.Development of progressive muscle weakness | back 3 4.Development of progressive muscle weakness |
front 4 The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? 1.Difficulty articulating words 2.Lung vital capacity of 10 mL/kg 3.Paralysis progressing from the toes to the waist 4.A blood pressure (BP) decrease from 110/78 mm Hg to 102/70 mm Hg | back 4 2.Lung vital capacity of 10 mL/kg |
front 5 The nurse reviews the primary health care provider's (PHCP's) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the PHCP would the nurse question? 1.Clear liquid diet 2.Bilateral calf measure 3.Monitor vital signs frequently 4.Passive range-of-motion (ROM) exercises | back 5 1.Clear liquid diet |
front 6 The nurse is evaluating the respiratory outcomes for a client with Guillain-Barré syndrome. The nurse determines that which are acceptable outcomes for the client? Select all that apply. 1.Spontaneous breathing 2.Oxygen saturation of 98% 3.Adventitious breath sounds 4.Normal arterial blood gas levels 5.Vital capacity within normal range | back 6 1.Spontaneous breathing 2.Oxygen saturation of 98% 4.Normal arterial blood gas levels 5.Vital capacity within normal range |
front 7 The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse understands that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. 1.Stroke 2.Pneumonia 3.Sleep apnea 4.Obstructive lung disease 5.Opioid analgesics, sedatives, anesthetics | back 7 1.Stroke 3.Sleep apnea 5.Opioid analgesics, sedatives, anesthetics |
front 8 The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis | back 8 3.Respiratory acidosis |
front 9 The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month | back 9 4.Respiratory or gastrointestinal infection during the previous month |
front 10 A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness? 1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors | back 10 3.Providing information, giving positive feedback, and encouraging relaxation |
front 11 The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room? 2.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Nasal cannula and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray | back 11 4.Electrocardiographic monitoring electrodes and intubation tray |