An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?

Check the medication list for interactions.

Put the client on safety precautions

Place the client on a bed alarm.

Assess the client's oxygen saturation

Answer and Explanation

The Correct Answer is D

A. Check the medication list for interactions. While some medications can cause confusion or restlessness, the priority in Guillain-Barré syndrome (GBS) is to assess for respiratory compromise, as GBS can lead to progressive neuromuscular paralysis, affecting breathing. Reviewing medications is important but not the first action.
B. Put the client on safety precautions. Clients with confusion and restlessness may need fall precautions, but the priority concern in GBS is respiratory function. If hypoxia is causing confusion, addressing oxygenation takes precedence over safety measures.
C. Place the client on a bed alarm. A bed alarm can help prevent falls if the client is confused or restless, but it does not address the underlying cause of these symptoms. Hypoxia-related confusion must be ruled out first before focusing on fall prevention.
D. Assess the client's oxygen saturation. Respiratory failure is the most serious complication of Guillain-Barré syndrome due to progressive paralysis of the diaphragm and intercostal muscles. Restlessness and confusion can be early signs of hypoxia, making it critical to assess oxygenation immediately. If oxygen saturation is low, the nurse should provide supplemental oxygen and notify the provider for further intervention, such as respiratory support or mechanical ventilation if necessary.

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Correct Answer is A

Explanation

A. Poor impulse control. A stroke in the right cerebral hemisphere affects judgment, attention, and impulse control. Clients often display poor safety awareness, impulsivity, and difficulty recognizing deficits (anosognosia), increasing the risk of falls and injury.
B. Unable to discriminate words and letters. This symptom is associated with left hemisphere strokes, which affect language centers such as Broca’s and Wernicke’s areas. Clients with left-sided strokes may experience aphasia, difficulty reading, and problems with word recognition, which are not typical of right hemisphere strokes.
C. Motor retardation. Right hemisphere strokes typically cause left-sided hemiparesis or hemiplegia but do not necessarily result in motor retardation (slowness of movement). Instead, lack of awareness of deficits is more common, leading to neglect of the affected side.
D. Deficits in the right visual field. Right hemisphere strokes cause left visual field deficits (left homonymous hemianopia). Right visual field deficits occur with left hemisphere strokes. Clients may also experience left-sided neglect, where they fail to recognize or respond to stimuli on their affected side.

A. "Medications for Alzheimer's disease will help slow the progression of my disease." B. "Medications for Alzheimer's disease will cure the disease." C. "Medications for Alzheimer's disease will help me remember what I forgot." D. "Medications for Alzheimer's disease will help to increase my energy levels."

Correct Answer is A

Explanation

A: "Medications for Alzheimer's disease will help slow the progression of my disease." This reflects the purpose of commonly prescribed medications, such as cholinesterase inhibitors and memantine. These medications aim to improve cognitive function and slow the progression of symptoms, though they do not cure the disease.
B: "Medications for Alzheimer's disease will cure the disease." There is currently no cure for Alzheimer's disease, and medications are intended to manage symptoms and potentially slow progression rather than provide a cure.
C: "Medications for Alzheimer's disease will help me remember what I forgot." Medications may improve memory and cognitive function to some extent, but they do not restore lost memories or fully resolve memory deficits.
D: "Medications for Alzheimer's disease will help to increase my energy levels." Medications for Alzheimer's focus on addressing cognitive decline and associated symptoms rather than increasing energy levels.

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An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is A

Explanation

A nurse is teaching a client who is newly diagnosed with Alzheimer's disease and their family about newly prescribed medications for Alzheimer's disease. Which statement by the client indicates the teaching was effective?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following medications should the nurse identify as a cause of this disorder?

The wife of a patient who has deterioration in memory asks the nurse whether her husband has Alzheimer's Disease. The nurse explains that a diagnosis of AD is usually made when what happens?

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A nurse is reviewing the electronic medical record of a middle-aged client who was admitted following a stroke. Which of the following findings should the nurse identify as a modifiable risk factor for stroke?