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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Sensorineural hearing loss is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). Sensorineural hearing loss can be mild, moderate, severe, or profound, and it affects the ability to hear faint sounds or understand speech. However, in the Rinne test, if the air-conducted sound is louder than the bone-conducted sound, it indicates that the patient’s hearing is likely normal.
Choice B rationale
Tinnitus is the perception of noise or ringing in the ears. It is a common problem that affects about 15 to 20 percent of people and is especially common in older adults. However, the Rinne test is not used to diagnose tinnitus. It is used to compare air and bone conduction of sound.
Choice C rationale
In a normal Rinne test, air conduction (AC) is better than bone conduction (BC). This is referred to as a positive Rinne test. If a patient reports that air-conducted sound is louder than bone-conducted sound, it suggests that the patient’s hearing is likely normal.
Choice D rationale
Otosclerosis is a condition that affects the bones in the middle ear, causing hearing loss. It is a common cause of conductive hearing loss, particularly in young adults. However, in otosclerosis, bone conduction (BC) is better than air conduction (AC), which is referred to as a negative Rinne test.

A. Speak slowly and clearly using yes/no Questions one at a time. B. Ask the family member if they know what the client wants. C. Keep repeating the same ultiple times. D. Put a cell phone in their right hand to text their Questions.

Correct Answer is A

Explanation

Choice A rationale
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale

Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse interpret this assessment finding?

Correct Answer is C

Explanation

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

Correct Answer is A

Explanation

A nurse is caring for a 46-year-old patient who has had a major ischemic stroke in the last 25 minutes. The patient’s vital signs are: Temp 98.7, HR: 98, RR: 28, BP: 165/98. Which medication does the nurse anticipate the doctor will order?

The nurse is providing patient education to a patient with early-stage Alzheimer’s disease (AD) and their family. The patient has been prescribed donepezil hydrochloride. What should the nurse explain to the patient and family about this drug?

A patient with hypotension has an order for 1000 mL of 0.9% Normal Saline over 3 hours. The tubing drop factor is 10 gtt/mL. How many gtt/min should be given? (This is a med math nd does not require options)

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?

The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

A nurse is administering a 350 mL unit of PRBCs over 3 hours to a client diagnosed with anemia. The nurse should set the IV pump to deliver how many mL/hr?

The patient with glaucoma is usually started on the lowest dose of medication. Which of the following is the preferred initial ophthalmic medication?

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?