A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that that the client's respiratory distress is caused by which of the following?

Degeneration of nerves in the brainstem and spinal cord.

Pleural effusion caused by immobility.

Demyelination of nerves that stimulate the respiratory muscles.

Bronchoconstriction and edema of the airways.

Answer and Explanation

The Correct Answer is C

A.   While GBS primarily affects peripheral nerves (nerves outside the brain and spinal cord), it does not typically cause direct degeneration of nerves in the brainstem and spinal cord. Therefore, this option is not correct in the context of respiratory distress in GBS.
B.   Pleural effusion caused by immobility: Pleural effusion, an accumulation of fluid in the pleural cavity around the lungs, is not a typical complication of GBS. It is more commonly associated with conditions such as heart failure, pneumonia, or malignancy, rather than directly with GBS.
C.   In Guillain-Barre Syndrome, demyelination of nerves affects the transmission of signals from the brain to the muscles, including those responsible for respiration. As a result, respiratory muscles may become weak or paralyzed, leading to shallow breathing and respiratory distress.
D.   While respiratory distress can occur in some neurological conditions due to autonomic dysfunction or secondary complications, such as aspiration pneumonia, bronchoconstriction and airway edema are not typical manifestations of GBS itself.

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Correct Answer is C

Explanation

A. Defibrillation is not typically indicated for atrial fibrillation. Atrial fibrillation involves disorganized electrical activity in the atria rather than a shockable rhythm like ventricular fibrillation or ventricular tachycardia. Therefore, emergency defibrillation is not appropriate for a client with persistent atrial fibrillation.
B. CABG is a surgical procedure used to improve blood flow to the heart muscle by bypassing blocked coronary arteries. It is primarily indicated for clients with significant coronary artery disease that cannot be managed effectively with medications or less invasive
C. Anticoagulant therapy, such as with medications like warfarin or direct oral anticoagulants (DOACs), is crucial for clients with atrial fibrillation. AFib predisposes individuals to an increased risk of stroke due to the potential formation of blood clots in the atria. Anticoagulants help prevent clot formation and reduce the risk of stroke.
D. Diuretics are medications that increase urine output and are often used to manage fluid overload or congestion in conditions such as heart failure or volume overload. However, diuretic therapy alone does not address the underlying rhythm abnormality of atrial fibrillation.

A. Soles of the feet B. Palms of the hands C. Oral mucosa D. Nail beds

Correct Answer is C

Explanation

A. The soles of the feet are not typically assessed for cyanosis because they are not a reliable indicator of central cyanosis. Cyanosis is best evaluated in areas where mucous membranes are visible.
B. Similar to the soles of the feet, the palms of the hands are not a reliable indicator of central cyanosis. Cyanosis is not typically visible on the palms unless there are severe systemic circulation issues.
C. The oral mucosa (inside the mouth) is a reliable area to assess for central cyanosis. The nurse can inspect the lips, tongue, and buccal mucosa for a bluish discoloration, which indicates decreased arterial oxygen saturation.
D. The nail beds are also a reliable indicator of central cyanosis. The nurse can assess the color of the nail beds and look for bluish discoloration, which can be more apparent in darker-skinned individuals compared to the lips and oral mucosa.

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A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that that the client's respiratory distress is caused by which of the following?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer is C

Explanation

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