A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome.
The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Assess the lung sounds.

Explain the progression of the syndrome.

Call the physician and prepare for intubation.

Encourage the client to cough.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.

Choice B rationale

While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.

Choice C rationale

Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.

Choice D rationale

Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.

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Correct Answer is C

Explanation

Choice A rationale
While assessing visual acuity may be part of a comprehensive eye examination, it would not specifically address distortions noted on the Amsler grid.
Choice B rationale
Tonometry testing is used to measure the pressure inside the eye and is typically used in the diagnosis of glaucoma. It would not specifically address distortions noted on the Amsler grid.
Choice C rationale
Distortions when looking at the Amsler grid can be a sign of macular degeneration16. Therefore, arranging for the client to be assessed for macular degeneration would be the appropriate action16.
Choice D rationale
While age-related changes in vision can occur, distortions when looking at the Amsler grid are not typically considered a normal age-related change16. Therefore, reassuring the client that this is an age-related change in vision would not be the appropriate action16.

A. It slows the progression of AD. B. It limits the physical effects of AD and other dementias. C. It removes the patient’s insight that they have AD. D. It cures AD in a small minority of patients.

Correct Answer is A

Explanation

Choice A rationale
Donepezil hydrochloride is a medication used to treat dementia related to Alzheimer’s disease. It works by improving mental function, such as memory and the ability to think and reason.
However, it is important to note that donepezil does not cure Alzheimer’s disease. The condition will worsen over time, even in people who take donepezil.
Choice B rationale
Donepezil does not limit the physical effects of Alzheimer’s disease and other dementias. While it can improve cognitive function, it does not directly impact the physical symptoms associated with these conditions.
Choice C rationale
Donepezil does not remove the patient’s insight that they have Alzheimer’s disease. It is a medication that helps to improve cognitive function, but it does not alter a person’s awareness or understanding of their condition.

Choice D rationale
Donepezil does not cure Alzheimer’s disease in any patients, let alone a small minority. It is a treatment that can help manage symptoms and improve cognitive function, but it does not stop the progression of the disease.

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A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has informed the Home Health Nurse that they recently noticed distortions when looking at the Amsler grid kept on their refrigerator. What is the appropriate action for the nurse to take?

Correct Answer is C

Explanation

The nurse is providing patient education to a patient with early-stage Alzheimer’s disease (AD) and their family. The patient has been prescribed donepezil hydrochloride. What should the nurse explain to the patient and family about this drug?

Correct Answer is A

Explanation

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A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome.
The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?