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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Measure abdominal girth according to a set routine. Abdominal enlargement is a common finding in clients with cirrhosis, which is a condition characterized by liver scarring and impaired liver function. Measuring abdominal girth regularly is an important nursing intervention to monitor the progression of abdominal distention and to identify potential complications such as ascites, which is an accumulation of fluid in the abdomen.
Choice A, reporting the condition to the physician immediately, may be necessary if the abdominal enlargement is sudden or accompanied by other symptoms such as severe pain or shortness of breath.
Choice B, providing the client with nonprescription laxatives, is not indicated for abdominal enlargement in clients with cirrhosis.
Choice D, asking the client about food intake, is not relevant to the assessment of abdominal enlargement in clients with cirrhosis.
Correct Answer is B
Explanation
Anemia from the decrease in the maturation of red blood cells. Erythropoietin, a hormone secreted by the kidneys, stimulates the production of red blood cells in the bone marrow. A decrease in erythropoietin secretion from the kidneys will result in a decrease in the maturation of red blood cells, leading to anemia.
Choice A, an increase in blood sugar levels due to alteration in insulin levels, and Choice C, Decrease in blood sugar levels due to alteration in insulin levels are not associated with decreased secretion of erythropoietin.
Choice D, Development of male sex characteristics is not related to the function of erythropoietin.
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