What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

"It must be difficult to accept your child's lifelong prognosis."

"Within days of treatment, your child will regain full recovery of their legs, and then their arms."

"The paralysis caused by this disease is temporary, but the recovery can take up to 2 years."

"In addition to the paralysis, your child will experience sensory loss."

Answer and Explanation

The Correct Answer is C

Choice A reason: This statement is not accurate and may cause unnecessary distress, as Guillain-Barré Syndrome often does not result in a lifelong prognosis.

Choice B reason: This statement is overly optimistic and may not be accurate, as recovery times can vary greatly between individuals.

Choice C reason: This response provides a realistic expectation without causing undue alarm, acknowledging the temporary nature of the paralysis and the potential duration of recovery.

Choice D reason: While sensory loss can occur, it is not guaranteed, and the focus should be on the respiratory paralysis and the recovery process.

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Correct Answer is C

Explanation

Choice A reason: Placing the infant flat and prone is not the first priority in the care of an infant with gastroschisis.
Choice B reason: While providing warmth and promoting bonding are important, they are not the immediate priority upon admission for an infant with gastroschisis.
Choice C reason: This is the correct choice. The exposed abdominal organs in gastroschisis must be protected immediately to prevent heat and fluid loss and to reduce the risk of infection.
Choice D reason: Breastfeeding is important for bonding and nutrition but is not the first intervention for an infant with gastroschisis.

A. The patient can only receive blood that has been donated by family members. B. Under no circumstances will the patient receive blood products. C. In an emergency, a court order can be obtained for the patient to receive blood transfusions. D. The patient can receive volume expanders.

Correct Answer is C

Explanation

The correct answer is: c. In an emergency, a court order can be obtained for the patient to receive blood transfusions.

Choice A: The patient can only receive blood that has been donated by family members.

Jehovah’s Witnesses refuse blood transfusions, including those from family members, due to their religious beliefs. They believe that both the Old and New Testaments command them to abstain from blood (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29). Therefore, this option is incorrect.

Choice B: Under no circumstances will the patient receive blood products.

While Jehovah’s Witnesses generally refuse blood transfusions, there are exceptional circumstances where medical professionals can seek a court order to administer blood transfusions, especially in life-threatening situations involving minors. Thus, this statement is not entirely accurate.

Choice C: In an emergency, a court order can be obtained for the patient to receive blood transfusions.

In life-threatening emergencies, especially involving minors, courts can intervene and issue orders to administer necessary medical treatments, including blood transfusions, despite parental objections based on religious beliefs. This ensures the child’s right to life and health is protected. Therefore, this is the correct answer.

Choice D: The patient can receive volume expanders.

Volume expanders can be used to increase blood volume and maintain circulation, but they do not carry oxygen or replace lost blood cells. While they are an option for managing blood loss, they are not a substitute for blood transfusions in severe cases of anemia or blood loss, which are common in leukemia patients. Thus, this option is not entirely correct.

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What is the best response by the nurse when the parents ask about the paralysis associated with Guillain-Barré Syndrome, which has affected the respiratory muscles and requires mechanical ventilation for their child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

Correct Answer is C

Explanation

A four-year-old patient has been diagnosed with leukemia. The patient's parents, who follow the Jehovah's Witness faith, inform the physician that they will not approve any type of blood transfusions. The pediatric nurse is aware that:

Correct Answer is C

Explanation

A parent asks the nurse if there is anything that can be done to reduce the pain that his 2-year-old experiences each morning when blood is drawn for lab studies. Which intervention is the best choice for the nurse to implement based on the parent's concern?

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Which of the following is of primary importance for a child who is admitted to the PICU for DKA (diabetic ketoacidosis)?

Which nursing diagnosis takes priority for a 15-year-old child with third-degree burns of the hands, face, and chest?

The nurse is giving a health promotion class to adolescents. The nurse will be sure to include information regarding the leading cause of death in adolescents aged 15 and up.

When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory-perceptual alterations. This problem is based on which etiology?

After surgery for the correction of bilateral congenital clubfeet, an infant returns with bilateral long-leg casts. The toes on both feet are edematous, yet there is color, sensitivity, and movement. What is the most appropriate action by the nurse?