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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
Slowing of activity, also known as bradykinesia, is a common symptom of Parkinson’s disease. It is characterized by a general reduction in the speed and amplitude of voluntary movements, leading to difficulties with tasks such as walking, talking, and performing other self-care activities.
Choice B rationale
Muscle flaccidity is not typically associated with Parkinson’s disease. Instead, people with Parkinson’s often experience muscle rigidity or stiffness.
Choice C rationale
A gait with the body leaning backward is not a typical symptom of Parkinson’s disease. People with Parkinson’s disease often have a stooped posture, with the body leaning forward.
Choice D rationale
Continuous tremors are a hallmark symptom of Parkinson’s disease, but they are not present in all cases. Tremors in Parkinson’s disease are often described as a “pill-rolling” tremor because the movement resembles the motion of trying to roll a pill between the thumb and index finger.

A. Prothrombin level B. Brain CT or MRI C. Chest x-ray D. Lumbar puncture

Correct Answer is B

Explanation

Choice A rationale

While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.

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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?

Nursing Test Bank

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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?