A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium (Tensilon) test.

A client with Bell's palsy who has an order for prednisone and acyclovir.

A client with Parkinson's disease who has hypokinetic dysarthria and a lack of facial expressions.

A client with multiple sclerosis who has bladder flaccidity and is retaining urine.

Answer and Explanation

The Correct Answer is A

A.   A client with myasthenia gravis who has bilateral ptosis and a positive edrophonium test is likely experiencing a myasthenic crisis, which is a life-threatening condition that requires immediate attention. This client would be the priority because they may require rapid intervention to maintain airway and breathing.
B.   Bell's palsy is characterized by sudden onset of facial paralysis due to inflammation of the facial nerve. While Bell's palsy can be distressing for the client, it does not typically require urgent intervention unless there are complications such as corneal abrasion due to inability to close the eye.
C.   Parkinson's disease is a chronic neurodegenerative disorder characterized by motor symptoms such as tremors, rigidity, bradykinesia (slowness of movement), and postural instability. While this client requires ongoing assessment and care, the symptoms described do not typically indicate an acute or urgent need for intervention.
D.   A client with multiple sclerosis who has bladder flaccidity and is retaining urine needs assessment and intervention to prevent complications such as urinary tract infections or renal damage. However, this is not as immediately life-threatening as a myasthenic crisis.

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Correct Answer is C

Explanation

A. While GBS primarily affects peripheral nerves (nerves outside the brain and spinal cord), it does not typically cause direct degeneration of nerves in the brainstem and spinal cord. Therefore, this option is not correct in the context of respiratory distress in GBS.
B. Pleural effusion caused by immobility: Pleural effusion, an accumulation of fluid in the pleural cavity around the lungs, is not a typical complication of GBS. It is more commonly associated with conditions such as heart failure, pneumonia, or malignancy, rather than directly with GBS.
C. In Guillain-Barre Syndrome, demyelination of nerves affects the transmission of signals from the brain to the muscles, including those responsible for respiration. As a result, respiratory muscles may become weak or paralyzed, leading to shallow breathing and respiratory distress.
D. While respiratory distress can occur in some neurological conditions due to autonomic dysfunction or secondary complications, such as aspiration pneumonia, bronchoconstriction and airway edema are not typical manifestations of GBS itself.

A. Atrial flutter B. Atrial fibrillation C. Unstable angina D. Premature atrial contractions (PACS)

Correct Answer is B

Explanation

A. Atrial flutter typically presents with a regular atrial rate (usually around 250-350 beats per minute) and a characteristic "sawtooth" pattern of flutter waves (F-waves) on the ECG. This condition would not present with irregular ventricular rates and is less likely based on the ECG findings described.

B. Atrial fibrillation is identified by an irregularly irregular rhythm and the absence of P-waves on the ECG, which is replaced by erratic activity.
C. Unstable angina presents with chest pain or discomfort due to reduced blood flow to the heart muscles, usually related to atherosclerotic plaque rupture or erosion. It does not cause the ECG findings described (absence of P-waves and irregular ventricular rate).
D. PACs are early atrial depolarizations that can cause palpitations but do not typically result in the absence of P-waves or irregular ventricular rates as described in the scenario.

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A nurse on a telemetry unit receives change-of-shift report on four clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that that the client's respiratory distress is caused by which of the following?

Correct Answer is C

Explanation

A client in an urgent care clinic is complaining of heart palpitations, fatigue, and shortness of breath. A 12-lead electrocardiogram (ECG) shows no discernable P-waves, and an irregular ventricular rate. The nurse should understand that this finding represents which of the following conditions?

Correct Answer is B

Explanation

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