Question

A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, "It is getting harder to take a deep breath." Which action by the nurse is most appropriate?

Answer 1

Correct Answers:

Call the physician and prepare for intubation.

Rationale :

The client’s report of increasing difficulty taking a deep breath is a sign of impending respiratory failure, a critical concern in Guillain-Barré syndrome.
This condition causes ascending paralysis, which can progressively weaken the respiratory muscles.
Early signs of respiratory compromise should be treated as emergencies, and immediate notification of the provider is necessary.
👍Preparing for intubation and mechanical ventilation ensures airway protection and adequate gas exchange before a full respiratory arrest occurs.
🚨Delaying action can result in life-threatening hypoxia or apnea.

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Answer 2

Correct Answers:

Provide close supervision because of the client's impulsiveness and poor judgment.

Rationale :

💎A right hemisphere stroke typically results in visual-spatial deficits, poor impulse control, and impaired judgment, which significantly increase the client’s risk for injury.

💎These clients often neglect the left side of their body and environment and may overestimate their abilities, making close monitoring essential to prevent falls or other accidents.

💎 Interventions focused on enhancing safety and providing constant supervision help mitigate these risks and support rehabilitation.

👍

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Answer 3

Correct Answers:

Speak slowly and clearly using yes/no questions one at a time.

Rationale :

Clients with aphasia experience difficulty with language comprehension and expression, often requiring simple, structured communication. 🧠
Using clear, slow speech and closed-ended (yes/no) questions reduces confusion and enhances understanding.
🧠Presenting one question at a time prevents cognitive overload and allows for focused processing.
This approach respects the patient’s communication ability while fostering effective interaction and reducing frustration.

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Answer 4

Correct Answers:

Instruct the client on daily muscle stretching.

Rationale :

💎Multiple sclerosis involves muscle weakness, spasticity, and fatigue, requiring interventions to maintain mobility and prevent complications such as contractures.
💎Teaching the client daily stretching routines promotes flexibility, maintains muscle tone, and supports independence in activities of daily living.
💎It also empowers the client to engage in self-care as tolerated, which is essential in managing a chronic, progressive condition like MS.
👍

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Answer 5

Correct Answers:

Antibiotic therapy.

Rationale :

Bacterial meningitis requires immediate antibiotic administration to prevent rapid neurological deterioration, sepsis, and death.
The goal is to eradicate the infecting organism, typically through broad-spectrum antibiotics, which may later be adjusted based on culture results.
✅Prompt treatment reduces inflammation of the meninges and improves survival outcomes. Delays in antibiotic therapy can be fatal in this time-sensitive infection.

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Answer 6

Correct Answers:

Ascending muscle weakness

Rationale :

Guillain-Barré syndrome is characterized by progressive, ascending paralysis, typically starting in the lower extremities and moving upward.
This autoimmune-mediated demyelinating disorder of the peripheral nerves can lead to life-threatening respiratory muscle involvement if not recognized early.

✅ The hallmark symptom is symmetrical motor weakness that ascends, often preceded by a viral infection.

✅ Early recognition allows for timely supportive care, including monitoring respiratory function.

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Answer 7

Correct Answers:

I should try to eat my food either very warm or very cold.

Rationale :

✔️Trigeminal neuralgia involves severe facial pain triggered by sensory stimuli, including temperature extremes.

Patients should be instructed to avoid very hot or cold food or drinks, as these can provoke pain episodes.
The correct approach includes using lukewarm food, chewing on the unaffected side, and minimizing face stimulation.
The client’s statement reflects a misunderstanding, requiring further teaching to prevent triggering painful episodes.

👍

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Answer 8

Correct Answers:

Brain CT or MRI

Rationale :

A client with suspected cerebrovascular accident (CVA) requires immediate neuroimaging to distinguish between ischemic and hemorrhagic stroke, which dictates treatment 🩺.
A non-contrast CT scan is typically the first diagnostic tool used due to its speed and ability to detect bleeding.
🔍 An MRI may follow to evaluate ischemic changes in greater detail.
These imaging techniques guide urgent management, including the possible use of thrombolytics if no hemorrhage is detected.

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Answer 9

Correct Answers:

Semi-solid food with thick liquids

Rationale :

Clients with Parkinson's disease often experience dysphagia due to weakened or uncoordinated muscles involved in swallowing.
Providing semi-solid foods and thickened liquids helps reduce the risk of aspiration, which is a major concern.
These food textures are easier to control during swallowing, enhancing nutritional intake and preventing complications such as aspiration pneumonia.

✔️ This dietary modification is a critical component of safe nutrition management in Parkinson’s care.

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Answer 10

Correct Answers:

You must avoid stress and extreme fatigue because they can trigger a relapse.

Rationale :

💎Relapsing-remitting multiple sclerosis (RRMS) is characterized by acute episodes of neurologic dysfunction followed by periods of remission.

💎 Stress and fatigue are well-known triggers for exacerbations, making energy conservation and stress management key components of care.

💎 Educating clients to avoid these triggers supports disease control and enhances quality of life. Preventative strategies, rather than solely reactive treatments, are essential in managing RRMS.

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RN Medsurg NRSG110

No.

1 : A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, "It is getting harder to take a deep breath." Which action by the nurse is most appropriate?

2 : The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

3 : The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

4 : The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client's care plan?

5 : The nurse is caring for a client who is suspected of meningitis. After reviewing lab results, the nurse will anticipate that the provider will prescribe which medications to treat the meningitis.

6 : In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?

7 : A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

8 : A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?

9 : While assessing the breath sounds of a client with Parkinson's disease, a nurse hears adventitious sounds. How should the client’s nutritional needs be met?

10 : A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). What instruction should the nurse provide?

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