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 A

Explanation

Choice A rationale
In the case of a major ischemic stroke, the medication that a nurse would anticipate the doctor to order is tissue plasminogen activator (tPA)8. This medication works by dissolving the clot that is blocking blood flow to the brain. It is most effective when given as soon as possible after the onset of stroke symptoms.
Choice B rationale

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain and reduce inflammation. It is not typically used in the treatment of ischemic stroke.
Choice C rationale
Aspirin is an antiplatelet drug that is sometimes used in the prevention of stroke. However, it is not typically used as an immediate treatment for a major ischemic stroke.
Choice D rationale
Warfarin is an anticoagulant medication that is used to prevent blood clots from forming or growing larger. It is not typically used as an immediate treatment for a major ischemic stroke.

A. Keep a urinary catheter in place for the entire duration of recovery. B. Provide three larger meals rather than frequent small meals. C. Limit the intake of insoluble fiber. D. Teach the patient to perform deep breathing and coughing exercises.

Correct Answer is D

Explanation

Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.

Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 46-year-old patient who has had a major ischemic stroke in the last 25 minutes. The patient’s vital signs are: Temp 98.7, HR: 98, RR: 28, BP: 165/98. Which medication does the nurse anticipate the doctor will order?

Correct Answer is A

Explanation

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Correct Answer is D

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?