A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

Unilateral upper extremity weakness

Bilateral ascending weakness

Mask like facial expressions

Pill rolling actions made by the clients fingers

Answer and Explanation

The Correct Answer is B

A) Unilateral upper extremity weakness:
Guillain-Barré Syndrome (GBS) typically presents with bilateral weakness, not unilateral. The weakness in GBS typically begins symmetrically in the lower extremities and ascends upward toward the upper body, including the arms, face, and respiratory muscles. Therefore, unilateral weakness is not characteristic of GBS, and its presence should prompt further investigation into other possible causes.

B) Bilateral ascending weakness:
One of the hallmark signs of Guillain-Barré Syndrome is ascending weakness, which means that the weakness usually starts in the lower extremities (legs) and progresses upwards to the upper extremities, face, and potentially the respiratory muscles. This bilateral ascending paralysis is a classic feature of GBS and occurs due to the immune system attacking the myelin sheath of peripheral nerves. The nurse should be vigilant for signs of progressive weakness, as GBS can quickly lead to respiratory failure and requires prompt intervention.

C) Mask-like facial expressions:
Mask-like facial expressions are more commonly associated with Parkinson's disease, not Guillain-Barré Syndrome. Parkinson’s disease is characterized by a reduction in facial expressiveness due to the loss of dopaminergic neurons, leading to a fixed, unblinking, or "masked" appearance. While facial involvement can occur in GBS as the weakness ascends, it is not typically described as a "mask-like" expression.

D) Pill rolling actions made by the client's fingers:
Pill-rolling is a characteristic tremor often associated with Parkinson's disease and involves the repetitive motion of the fingers, as if rolling a pill. It is a resting tremor seen in Parkinson's disease and not in Guillain-Barré Syndrome. GBS primarily presents as weakness and loss of motor function, rather than tremors or other involuntary movements.

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Correct Answer is D

Explanation

A) Assess the client's potassium level:
While electrolyte imbalances, including low potassium, can contribute to symptoms like restlessness or muscle weakness, it is not the first priority in a client with COPD who suddenly becomes restless and anxious. Restlessness and anxiety in this context are more likely to be due to hypoxia (low oxygen levels), hypercapnia (high carbon dioxide levels), or respiratory distress.

B) Check the client's temperature:
An elevated temperature may indicate an infection, such as pneumonia or a respiratory tract infection, which can exacerbate COPD symptoms. However, in the context of sudden restlessness and anxiety, this is less likely to be the most immediate cause. The primary concern should be addressing the potential respiratory issues, such as hypoxia or acute exacerbation, rather than focusing on fever, unless other signs of infection are present.

C) Increase the client's oxygen flow rate to 15 L/min:
While it is important to ensure adequate oxygenation in a client with COPD, increasing the oxygen flow rate to 15 L/min may not be appropriate, as COPD patients are typically at risk for oxygen-induced hypercapnia. These patients often rely on low levels of oxygen to stimulate breathing, and administering high-flow oxygen can suppress their respiratory drive, potentially worsening carbon dioxide retention.

D) Encourage the client to perform pursed-lip breathing:
Pursed-lip breathing is a highly effective technique for COPD patients to help increase oxygenation and decrease the work of breathing. This technique involves the client breathing in through the nose and exhaling slowly through pursed lips, which helps to keep the airways open longer and facilitates the removal of trapped air in the lungs.

A. Use a razor to shave the hair in the treated area. B. Wash treated area gently with lukewarm water and mild soap. C. Purchase aloe approved skin-care products D. Wear loose-fitting, soft clothing over the treated skin. E. Sun tan the affected area for no more than 30 minutes a day

Correct Answer is ["B","C","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

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A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client with COPD that suddenly becomes restless and anxious. Which of the following steps should the nurse take next?

Correct Answer is D

Explanation

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

Correct Answer is ["B","C","D"]

Explanation

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