1.
A female client with Guillain-Barré syndrome with paralysis affecting the respiratory muscles. The client requires mechanical ventilation. How should the nurse respond when the client asks the nurse about the paralysis?
Correct Answer
A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”
Explanation
The correct answer is "You may have difficulty believing this, but the paralysis caused by this disease is temporary." This response is appropriate because it provides accurate information to the client. Guillain-Barré syndrome is known to cause temporary paralysis, and it is important for the nurse to provide reassurance and support to the client. This response acknowledges the client's potential disbelief while also providing them with hope for recovery.
2.
A female client is admitted to the hospital who has a diagnosis of Guillain-Barre syndrome. The nurse asks during the nursing admission interview if the client has history of:
Correct Answer
D. Respiratory or gastrointestinal infection during the previous month.
Explanation
Patients with Guillain-Barre syndrome often have a preceding respiratory or gastrointestinal infection. This is because Guillain-Barre syndrome is believed to be an autoimmune response triggered by an infection. The immune system mistakenly attacks the peripheral nervous system, leading to inflammation and muscle weakness. Therefore, it is important for the nurse to ask about any recent respiratory or gastrointestinal infections in order to assess the potential cause of the client's Guillain-Barre syndrome.
3.
Paralysis that accompanies Guillain-Barré syndrome is only temporary.
Correct Answer
A. True
Explanation
The statement is true because paralysis that occurs in Guillain-Barré syndrome is usually temporary. Guillain-Barré syndrome is a rare neurological disorder where the body's immune system mistakenly attacks the peripheral nerves. This can result in muscle weakness and paralysis. However, with proper medical treatment and rehabilitation, most people with Guillain-Barré syndrome are able to recover and regain their muscle function over time. Therefore, the correct answer is true.
4.
A female client who has Guillain-Barré syndrome has ascending paralysis. She is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to assist the client cope with this illness?
Correct Answer
C. Providing information, giving positive feedback, and encouraging relaxation
Explanation
The nurse would incorporate the strategy of providing information, giving positive feedback, and encouraging relaxation in the plan of care to assist the client cope with Guillain-Barré syndrome. This strategy helps the client feel empowered and involved in their care decisions, which can reduce anxiety and promote a sense of control. Providing information about the illness and treatment can also help the client understand what is happening to their body and what to expect. Giving positive feedback and encouraging relaxation techniques can help the client manage stress and promote a positive mindset during their recovery.
5.
A male client who has Guillain-Barré syndrome develops respiratory acidosis because of reduced alveolar ventilation. Which combination of arterial blood gas values confirms respiratory acidosis?
Correct Answer
D. pH, 7.25; PaCO2 50 mm Hg
Explanation
The combination of a pH of 7.25 and a PaCO2 of 50 mm Hg confirms respiratory acidosis. In respiratory acidosis, there is an accumulation of carbon dioxide (PaCO2) in the blood, leading to a decrease in pH. A pH of 7.25 indicates acidosis, as it is below the normal range of 7.35-7.45. Additionally, a PaCO2 of 50 mm Hg is above the normal range of 35-45 mm Hg, further confirming respiratory acidosis.
6.
A client with Guillain-Barré syndrome has remained on a ventilator for three weeks and can communicate only with eye blinks because of quadriplegia. The intensive care nursing staff usually have no time for this tedious communication process. How should the nurse reply to the family’s request for exemption from visiting hours?
Correct Answer
D. Make an exception to visiting regulations because of the long-term nature of the client’s recovery and the need for family support.
Explanation
The nurse should make an exception to visiting regulations because of the long-term nature of the client's recovery and the need for family support. Guillain-Barré syndrome is a serious condition that can cause paralysis, and the client's ability to communicate is limited to eye blinks. The family's presence and support can be crucial in providing emotional and psychological support to the client during this difficult time. Allowing the family to visit outside of regular visiting hours would help maintain the client's socialization needs and facilitate communication with the nursing staff.
7.
Guillain-Barré syndrome will never cause fear and anxiety.
Correct Answer
B. False
Explanation
Guillain-Barré syndrome is a rare neurological disorder that can cause muscle weakness and paralysis. It is understandable that individuals diagnosed with this syndrome may experience fear and anxiety due to the sudden onset of symptoms and uncertainty about their prognosis. Therefore, the statement that Guillain-Barré syndrome will never cause fear and anxiety is false.
8.
Which patient should be with the traveling nurse who is new to neurologic nursing care and has been in the neurologic unit for 1 week?
Correct Answer
B. A 68-year-old patient who has chronic amyotropHic lateral sclerosis (ALS)
Explanation
The correct answer is a 68-year-old patient who has chronic amyotrophic lateral sclerosis (ALS). This patient would be the best choice for the traveling nurse who is new to neurologic nursing care because ALS is a chronic condition that requires ongoing care and management. The nurse would have the opportunity to gain experience and familiarity with the specific needs and challenges of caring for patients with ALS. Additionally, the patient's age suggests that they may have been living with ALS for a longer period of time, providing the nurse with the opportunity to learn from their experiences and potentially receive guidance from other healthcare professionals who have been involved in their care.
9.
A disease that ends in degeneration of the basal ganglia and cerebral cortex.
Correct Answer
C. Huntington’s disease
Explanation
Huntington's disease is a genetic disorder that causes degeneration of the basal ganglia and cerebral cortex. This leads to various symptoms such as involuntary movements, cognitive decline, and psychiatric disturbances. It is caused by a mutation in the huntingtin gene and typically manifests in adulthood. The progressive degeneration of these brain regions is responsible for the characteristic symptoms of Huntington's disease.
10.
A male client gets hospitalized with Guillain-Barre Syndrome. ______ is the most significant.
Correct Answer
A. Even, unlabored respirations
Explanation
Even, unlabored respirations are the most significant in a male client hospitalized with Guillain-Barre Syndrome. This is because Guillain-Barre Syndrome affects the peripheral nervous system, leading to muscle weakness and paralysis. Respiratory muscles can also be affected, resulting in difficulty breathing. Therefore, the presence of even, unlabored respirations indicates that the client's respiratory muscles are functioning adequately, which is crucial for maintaining oxygenation and preventing respiratory distress. A soft, nondistended abdomen is also important but not as significant as respiratory function in this case.