When caring for a patient with Guillain-Barré Syndrome, which of the following is the most critical assessment the nurse should prioritize?

Assessing respiratory function

Monitoring blood glucose levels

Checking for skin breakdown

Monitoring for signs of infection

Answer and Explanation

The Correct Answer is A

A.   Assessing respiratory function is critical as respiratory muscle involvement can lead to respiratory failure.
B.   Monitoring blood glucose levels is important but not the priority in this context.
C.   Checking for skin breakdown is important but secondary to respiratory assessment.
D.   Monitoring for signs of infection is necessary but less urgent than assessing respiratory status.

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Correct Answer is A

Explanation

A. Weakness is a hallmark symptom of myasthenia gravis, resulting from the impaired transmission of nerve impulses to muscles. Monitoring for weakness is crucial to assess the progression of the disease.
B. Confusion is not typically a direct manifestation of myasthenia gravis; it may occur due to other factors but is not a primary concern.
C. Increased intracranial pressure is not associated with myasthenia gravis. The condition primarily affects muscle strength.
D. Increased urinary output is not relevant to myasthenia gravis and does not indicate a manifestation of the disease.

A. A client who has muscle hypertrophy. B. Moon face C. A client who has a positive Chvostek's sign. D. A client who has a butterfly rash on his face.

Correct Answer is B

Explanation

A. Muscle hypertrophy is not associated with hypercortisolism; instead, muscle wasting occurs.
B. Moon face is a characteristic sign of Cushing's syndrome (hypercortisolism).
C. A positive Chvostek's sign indicates hypocalcemia, not hypercortisolism.
D. A butterfly rash on the face is indicative of systemic lupus erythematosus, not hypercortisolism.

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When caring for a patient with Guillain-Barré Syndrome, which of the following is the most critical assessment the nurse should prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Correct Answer is A

Explanation

A nurse is assessing four clients on a medical unit. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism?

Correct Answer is B

Explanation

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

A young adult client with a new diagnosis of rheumatoid arthritis states, "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify the client is exhibiting which of the following defense mechanisms?

A nurse is setting goals for a client who has AIDS and is at the end of life. Which of the following are realistic goals?

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

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