A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...

intubation and mechanical ventilation.

IV infusion of (Sandoglobulin).

administration of methylprednisolone (Solu-Medrol).

insertion of a nasogastric (NG) feeding tube

Answer and Explanation

The Correct Answer is B

Choice A rationale: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.

Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.

Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.

Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.

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Correct Answer is B

Explanation

Choice A rationale: This does not match the peak time of NPH insulin.
Choice B rationale: This does not match the peak time of NPH insulin.
Choice C rationale: This does not match the peak time of NPH insulin.
Choice D rationale: This is because NPH insulin is an intermediate-acting insulin that has an onset of action of 1 to 2 hours, a peak of 6 to 12 hours, and a duration of 18 to 24 hours. Therefore, if Albert is given NPH insulin at 0730, the peak effect will occur between 1330 and 1930, which means that his blood glucose level will be lowest during this time.

A. Perform active range of motion three times daily. B. Maintain the head of bed in a flat or 30 degree position. C. Teach measures to avoid the Valsalva maneuver. D. Monitor for Battle's sign every four hours.

Correct Answer is C

Explanation

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

Correct Answer is C

Explanation

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