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?
Assess the lung sounds.
Explain the progression of the syndrome.
Call the physician and prepare for intubation.
Encourage the client to cough.
The Correct Answer is C
Choice A rationale
Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.
Choice B rationale
While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.
Choice C rationale
Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.
Choice D rationale
Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: = b. Prostaglandins
Choice A: Carbonic anhydrase inhibitors: These medications can be used for glaucoma, but they are not typically the first-line treatment due to potential side effects.
Choice B: Prostaglandins (Correct Answer) These are often the preferred initial medication for glaucoma because they are effective at lowering eye pressure, have minimal systemic side effects, and are typically used once daily.
Choice C: Alpha-agonists: These medications can be used as an adjunct to other glaucoma medications but are not usually the first choice due to potential side effects like dry mouth and fatigue.
Choice D: Beta-blockers: While once a common first-line treatment, beta-blockers have been largely replaced by prostaglandins due to potential side effects like slowed heart rate and worsened breathing problems.
Correct Answer is B
Explanation
Choice A rationale
This statement is not accurate. Relapsing-remitting multiple sclerosis (RRMS) is characterized by periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These episodes are followed by periods of remission, where the disease does not progress. Therefore, RRMS does not cause a steady and gradual decline in function.
Choice B rationale
This is the correct answer. Stress and extreme fatigue can trigger a relapse in RRMS1. Therefore, it is important for patients to avoid these triggers to manage their symptoms effectively.
Choice C rationale
This statement is incorrect. RRMS is the most common disease course at the time of diagnosis. It is not the least common type of multiple sclerosis.
Choice D rationale
This statement is not accurate. Medications for RRMS, known as disease-modifying treatments (DMT), are designed to reduce the frequency and severity of relapses. They are not intended to be taken only during times of relapse, but rather on an ongoing basis to manage the disease.
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