Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?

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Question 1 of 5

Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?

Correct Answer: C

Rationale: Patients with Guillain-Barre Syndrome are at risk for respiratory complications due to muscle weakness and paralysis, particularly affecting the respiratory muscles. Monitoring arterial blood gas (ABG) levels is crucial in assessing respiratory function and detecting respiratory failure early in these patients. ABG levels provide information on oxygenation, ventilation, and acid-base balance, which are essential parameters to monitor closely in patients with Guillain-Barre Syndrome to prevent respiratory compromise and potential respiratory failure. Regular ABG monitoring helps healthcare providers intervene promptly if respiratory abnormalities develop, ensuring timely treatment and preventing serious complications.

Question 2 of 5

The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?

Correct Answer: D

Rationale: Edrophonium (Tensilon) is a short-acting cholinesterase inhibitor used in the Tensilon test to aid in the diagnosis of myasthenia gravis. In patients with myasthenia gravis, there is a deficiency of acetylcholine at the neuromuscular junction, leading to muscle weakness. By inhibiting the breakdown of acetylcholine, edrophonium temporarily increases the availability of acetylcholine at the neuromuscular junction.

Question 3 of 5

A client has undergone the Snellen eye chart test and has 20/40 vision. Which of the ff is true for this client?

Correct Answer: A

Rationale: In the Snellen eye chart test, the first number (20) represents the distance at which the client is standing from the chart, while the second number (40) represents the distance at which a person with normal vision can read the same line on the chart. A person with 20/40 vision can see letters at 20 feet that a person with normal vision can see at 40 feet. This means that the client's vision is below the standard for normal vision, indicating that they may need corrective lenses to improve their visual acuity.

Question 4 of 5

Which of the ff. would the nurse explain to a patient is the main purpose of a hearing aid?

Correct Answer: D

Rationale: The main purpose of a hearing aid is to improve the patient's ability to hear. Hearing aids are devices designed to amplify sound for individuals with hearing loss or difficulty hearing. They do not amplify background noise or musical sounds specifically; instead, they are meant to enhance the overall perception of sounds to help individuals better understand speech and communicate effectively. Moreover, hearing aids do not occlude the ear, but rather are used to transmit sound into the ear canal to make sounds louder and clearer for the wearer.

Question 5 of 5

A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?

Correct Answer: A

Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.

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