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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Loss of peripheral vision is a hallmark sign of primary open-angle glaucoma. In POAG, increased intraocular pressure causes damage to the optic nerve, leading to a gradual loss of peripheral vision. This vision loss is often subtle and progresses slowly, making it difficult for individuals to notice until the condition is advanced.
B. Opacity of the lens is characteristic of cataracts, not glaucoma. Cataracts involve the clouding of the eye's natural lens, which leads to blurred vision and difficulties with seeing clearly, particularly in bright light. While cataracts and glaucoma can occur simultaneously, opacity of the lens is not indicative of POAG.
C. Decrease in color perception can be associated with various eye conditions, including age-related macular degeneration (AMD) and certain types of retinal diseases. While it can occur in glaucoma as the disease progresses, it is not the primary or most characteristic sign of POAG.
D. Pain and purulent discharge are more associated with acute conditions such as conjunctivitis (pink eye) or an eye infection, rather than primary open-angle glaucoma. POAG typically presents without pain or discharge, as it is a chronic condition with a gradual onset of symptoms.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Myasthenia Gravis
Myasthenia Gravis (MG) is an autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles. Key features include fluctuating muscle weakness that typically worsens with activity and improves with rest, bilateral ptosis (drooping of the eyelids), and difficulty with swallowing and speaking. The fact that the client's facial muscle strength is better in the morning and worsens throughout the day is a hallmark of MG. The edrophonium (Tensilon) test is specifically used to diagnose MG by temporarily improving muscle strength.
Antibodies at the neuromuscular junction
Myasthenia Gravis is caused by the presence of autoantibodies that target acetylcholine receptors at the neuromuscular junction, leading to impaired communication between nerves and muscles. This is consistent with the described symptoms and the use of the edrophonium (Tensilon) test to diagnose the condition.
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