A nurse is admitting a client who has Guillain-Barre syndrome. The client complains of an inability to move both legs and reports a tingling sensation above the waistline. Which is the most important piece of equipment for the nurse to keep at this client's bedside?
Incentive spirometer
Hoyer lift
Intubation tray
Nebulizer
The Correct Answer is C
A. This is useful for preventing atelectasis in patients who are unable to take deep breaths, but it is not the most critical piece of equipment for this client at this time.
B. While a Hoyer lift may be needed for mobility assistance in the future, it is not the most immediate priority.
C. Guillain-Barre syndrome can rapidly progress, leading to respiratory muscle weakness and the need for mechanical ventilation. Having an intubation tray readily available is crucial to ensure a prompt response if the client's respiratory status deteriorates.
D. A nebulizer is used to deliver medication to the lungs, but it is not the most critical piece of equipment for this client at this time.
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Related Questions
Correct Answer is C
Explanation
A. Fluid volume deficit, or dehydration, occurs when the body loses more fluid than it takes in. In this case, the patient has very low urine output, indicating that the kidneys are not excreting enough fluid. Despite the low urine output, the presence of pitting edema suggests that the patient is actually retaining fluid rather than losing it.
B. Bradycardia is defined as a heart rate slower than 60 beats per minute. While electrolyte imbalances and fluid imbalances can affect heart rate, bradycardia is not the primary concern associated with the combination of pitting edema and low urine output in this situation.
C. Hypertension (high blood pressure) is a common complication in acute glomerulonephritis. The condition often leads to fluid retention due to reduced kidney function and increased sodium and fluid retention. The presence of pitting edema and very low urine output suggests that the kidneys are not effectively removing excess fluid, which can lead to increased blood pressure.
D. Hyperglycemia refers to elevated blood glucose levels. Acute glomerulonephritis is not directly associated with hyperglycemia. While patients with diabetes can develop renal issues, hyperglycemia itself is not a typical direct complication of acute glomerulonephritis.
Correct Answer is D
Explanation
A. Cushing syndrome is characterized by excessive levels of cortisol in the body, often due to an adrenal gland tumor or prolonged use of corticosteroid medications. The primary symptoms include weight gain, hypertension, and changes in skin appearance. Exophthalmos is not typically associated with Cushing syndrome.
B. Hashimoto's disease is an autoimmune thyroid disorder that leads to hypothyroidism (underactive thyroid). The condition is characterized by symptoms such as fatigue, weight gain, cold intolerance, and dry skin. Exophthalmos is not a feature of Hashimoto's disease. Instead, it is more commonly associated with hyperthyroidism.
C. Addison's disease is a condition caused by inadequate production of cortisol and aldosterone by the adrenal glands. Symptoms include fatigue, weight loss, hyperpigmentation of the skin, and low blood pressure. Exophthalmos is not related to Addison's disease.
D. Graves' disease is an autoimmune hyperthyroid condition that leads to an overproduction of thyroid hormones. One of the hallmark symptoms of Graves' disease is exophthalmos or protruding eyes, caused by inflammation and swelling of the tissues around the eyes. This condition is directly associated with exophthalmos.
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