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 ["35 "]

Explanation

Step 1 is to calculate the total daily dosage in milligrams. This is done by multiplying the weight of the client by the ordered daily dosage. So, 70 kg × 25 mg/kg = 1750 mg/day.

Step 2 is to divide the total daily dosage by the number of doses per day to get the dosage per dose. So, 1750 mg ÷ 2 = 875 mg/dose.

Step 3 is to calculate the volume of the dose in milliliters. The supply of Amoxicillin is 125 mg/5 mL, which means there are 125 mg of Amoxicillin in every 5 mL. So, to find out how many milliliters contain 875 mg, we set up a proportion: (125 mg / 5 mL) = (875 mg / x mL). Solving for x gives x = (875 mg × 5 mL) ÷ 125 mg = 35 mL. Therefore, the correct dosage for one dose is 35 mL.

A. You will have a steady and gradual decline in function. B. You must avoid stress and extreme fatigue because it can trigger a relapse. C. Your type of multiple sclerosis is the least common, making it difficult to manage. D. You should take your medications only during times of relapse.

Correct Answer is B

Explanation

Choice A rationale
This statement is not accurate. Relapsing-remitting multiple sclerosis (RRMS) is characterized by periods of new symptoms or relapses that develop over days or weeks and usually improve partially or completely. These episodes are followed by periods of remission, where the disease does not progress. Therefore, RRMS does not cause a steady and gradual decline in function.
Choice B rationale
This is the correct answer. Stress and extreme fatigue can trigger a relapse in RRMS1. Therefore, it is important for patients to avoid these triggers to manage their symptoms effectively.
Choice C rationale
This statement is incorrect. RRMS is the most common disease course at the time of diagnosis. It is not the least common type of multiple sclerosis.
Choice D rationale
This statement is not accurate. Medications for RRMS, known as disease-modifying treatments (DMT), are designed to reduce the frequency and severity of relapses. They are not intended to be taken only during times of relapse, but rather on an ongoing basis to manage 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

Correct Answer is ["35 "]

Explanation

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). What instruction should the nurse provide?

Correct Answer is B

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?