The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds.

Increased pulse rate, respirations of 16 breaths/minute.

Decreased pulse rate, respirations of 20 breaths/minute.

Decreased pulse rate, abdominal breathing.

Answer and Explanation

The Correct Answer is A

Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.

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Correct Answer is B

Explanation

Assess the client for the ability to ambulate independently. The highest priority nursing intervention for a client admitted to a neurologic rehabilitation unit following a cerebrovascular accident is to assess the client's ability to ambulate independently. This assessment will help the nurse determine the level of assistance required and develop an appropriate care plan.

Option A. Providing instruction on blood-thinning medication is not the highest priority as it can be done later when the client's ambulation status is stable.

Option C. Including the client in the planning of care and setting of goals is important but not the highest priority in this situation as it can be done after assessing the client's ambulation status.

Option D. Praise the client when using adaptive equipment, is not the highest priority as the client's ambulation status is more important at this point.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

The correct answer is nephron. The nephron is the smallest structure in the kidneys that forms urine, and it is composed of the renal corpuscle and the renal tubule.

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The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

Correct Answer is B

Explanation

The nursing instructor is holding a clinical discussion with students in a renal unit in the hospital. The instructor asks about what is the smallest structure in the kidneys that forms urine. One of the students states that the dropdownis the functional unit of the kidney that forms the urine.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

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