The nursing management of a client with Guillain-Barré syndrome who is immobile should concentrate on what aspects of care once the respiratory system has been managed?

Correct Answer: A

Rationale: The correct answer is A) Turn the client every 2 hours to prevent skin breakdown. This is essential in the nursing management of a client with Guillain-Barré syndrome who is immobile. Turning the client frequently helps in preventing pressure ulcers, which can develop due to prolonged immobility. Option B) Range-of-motion (ROM) exercises every 8 hours is not the priority in this situation. While ROM exercises are important for maintaining joint mobility and preventing contractures, preventing skin breakdown takes precedence in an immobile client to avoid serious complications. Option C) Encouraging the client to participate in self-care may not be feasible in a client with Guillain-Barré syndrome who is immobile due to the severity of the condition. The focus should be on providing necessary care and support to meet the client's needs. Option D) Consulting with a physical or occupational therapist on independence activities is important in the rehabilitation phase of Guillain-Barré syndrome when the client starts to regain mobility. However, in the acute phase when the client is immobile, the priority is to prevent complications like skin breakdown. In an educational context, understanding the priorities in nursing care for clients with neurological conditions like Guillain-Barré syndrome is crucial for providing safe and effective care. Nurses need to prioritize interventions based on the client's condition and immediate needs to prevent complications and promote recovery.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Medulla. The medulla oblongata is a vital part of the brainstem responsible for regulating essential autonomic functions like respiration, vasomotor control, and heart function. Damage to the medulla can lead to significant disruptions in these crucial processes, resulting in the described symptoms. Option B) Cerebellum is incorrect because the cerebellum primarily plays a role in motor coordination and balance, not in regulating autonomic functions related to respiration, vasomotor, and cardiac activity. Option C) Parietal lobe is incorrect as the parietal lobe is mainly involved in sensory processing, spatial awareness, and perception, not in controlling autonomic functions like breathing or heart rate. Option D) Wernicke's area is incorrect because Wernicke's area is associated with language comprehension, not with the regulation of respiratory, vasomotor, or cardiac functions. Understanding the functions of different parts of the brain is crucial in clinical practice, especially in emergency situations where quick and accurate assessments are necessary to provide appropriate care. Knowledge of neuroanatomy helps healthcare professionals make informed decisions and interventions based on the presenting symptoms and their underlying neurological causes.

Correct Answer: A

Rationale: The correct answer is A) The most important aspect of care is to monitor the patient's respiratory rate and depth and vital capacity. During the acute phase of Guillain-Barré syndrome, patients are at high risk for respiratory compromise due to muscle weakness, particularly affecting the diaphragm. Monitoring these respiratory parameters is crucial for early detection of respiratory distress and the need for interventions such as mechanical ventilation. Option B is incorrect because early treatment with corticosteroids is not recommended for Guillain-Barré syndrome as it can worsen the condition by suppressing the immune response needed for recovery. Option C is incorrect as the most serious complication is paralysis due to ascending muscle weakness, not ascending demyelination. Option D is incorrect because Guillain-Barré syndrome can affect both voluntary and autonomic nervous systems, leading to potential complications like fluctuations in heart rate and blood pressure. In an educational context, understanding the importance of respiratory monitoring in Guillain-Barré syndrome highlights the critical role nurses play in the care of these patients. By closely monitoring respiratory status, nurses can intervene promptly and prevent respiratory failure, ultimately improving patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Evidence of continued compression of the cord is apparent. Early surgical therapy in patients with spinal cord injury is crucial when there is ongoing compression of the spinal cord. This compression can lead to further damage and worsening neurological deficits if not addressed promptly. Surgical intervention aims to relieve the pressure on the spinal cord, stabilize the spine, and prevent secondary injuries. Option A) There is incomplete cord lesion involvement: While this may be a consideration in the overall management of spinal cord injury, it is not a specific indication for early surgical therapy. Option B) The ligaments that support the spine are torn: While this may indicate instability in the spine and require surgical intervention, it is not a direct indication for early surgery in the context of spinal cord injury. Option C) A high cervical injury causes loss of respiratory function: While loss of respiratory function is a serious complication of high cervical spinal cord injury, it does not necessarily indicate the need for immediate surgical intervention unless there is evidence of cord compression. Educational Context: Understanding the rationale for early surgical therapy in spinal cord injury is essential for healthcare providers caring for these patients. Prompt recognition of indications for surgery can lead to better outcomes and prevent further neurological deterioration. It is crucial to consider the specific criteria that warrant surgical intervention to provide optimal care for patients with spinal cord injuries.

Correct Answer: D

Rationale: The correct answer is D) Cartilage. Cartilage is a connective tissue found in joints between bones, providing cushioning and facilitating smooth movement. As a person ages, cartilage can degenerate, leading to increased rigidity and decreased flexibility in the joints. This is a common phenomenon in conditions like osteoarthritis. Option A) Actin and C) Myosin are proteins found in muscle fibers and are involved in muscle contraction, not in the structure of joints or flexibility of tissues. Option B) Fascia is a connective tissue that surrounds muscles and other structures, providing support and protection. While fascia plays a role in movement and flexibility, it is not the primary tissue responsible for the loss of elasticity described in the scenario. Educationally, understanding the role of different tissues in the body is crucial for healthcare professionals in assessing and managing conditions affecting the musculoskeletal system. Recognizing the impact of aging on cartilage and joint health can help in early detection and intervention to improve quality of life for older patients.