ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 44 Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?
Correct Answer: C
Rationale: Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator may be needed, but emergency equipment should be available.
Question 5 of 5
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
Correct Answer: A
Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. While it is important to avoid injury, this is not specific to corticosteroid use.