ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 44 : Care of Patients with Problems of the Peripheral Nervous System Questions
Question 1 of 5
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
Correct Answer: B,D
Rationale: Cutting food up into smaller bites makes it easier for the client to chew and swallow. The UAP can weigh the client daily to monitor nutritional status. Assessing the gag reflex and monitoring potassium levels are tasks that require nursing judgment and cannot be delegated to UAP. Thickening liquids is typically a nursing or dietary intervention, not a UAP task.
Question 2 of 5
The nurse caring for a client with Guillain-Barr?© syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
Correct Answer: A,B,E
Rationale: Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy for nutritional support. While support groups, social work, or chaplain referrals may be needed, they do not directly help with mobility.
Question 3 of 5
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
Correct Answer: C
Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
Question 4 of 5
The nurse learns that the pathophysiology of Guillian-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what?
Correct Answer: D
Rationale: Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
Question 5 of 5
A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.