The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

Depressing the MDI two times into the spacer before inhaling

Inhaling slowly through spacer and holding breath for 10 seconds

Holding breath for 30 seconds between inhalations

Inhaling then exhaling quickly into the spacer

Answer and Explanation

The Correct Answer is C

A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.

B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.

C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.

D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.

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Correct Answer is C

Explanation

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

A. Partially compensated metabolic alkalosis B. Partially compensated metabolic acidosis C. Fully compensated respiratory acidosis D. Fully compensated respiratory alkalosis

Correct Answer is B

Explanation

A) Partially compensated metabolic alkalosis:
Metabolic alkalosis is typically characterized by an elevated pH and a high bicarbonate level (HCO3 >26 mEq/L). In this scenario, the pH is normal (7.44), and the bicarbonate level (HCO3 18 mEq/L) is low, which does not support a diagnosis of metabolic alkalosis. Furthermore, there is no evidence of compensation by respiratory mechanisms (i.e., low PaCO2). Therefore, this is not a likely diagnosis.

B) Partially compensated metabolic acidosis:
The ABG values indicate metabolic acidosis with a low bicarbonate level (HCO3 18 mEq/L) and a pH of 7.44, which is on the higher end of the normal range. A lower-than-normal bicarbonate level suggests an acidotic state, but the pH is compensating toward normal. The PaCO2 of 30 mmHg indicates a compensatory respiratory alkalosis, which would lower the PaCO2 to try to offset the acidosis. This represents a partially compensated metabolic acidosis, where the body is attempting to compensate for the acidosis but has not fully done so.

C) Fully compensated respiratory acidosis:
Respiratory acidosis is associated with elevated levels of carbon dioxide (PaCO2 >45 mmHg), which leads to a drop in pH. However, in this scenario, the PaCO2 is only 30 mmHg, which is lower than the normal range (35-45 mmHg), indicating that the problem is not respiratory acidosis. Additionally, fully compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and compensatory elevation in bicarbonate levels. Thus, this option does not fit the ABG values.

D) Fully compensated respiratory alkalosis:
Respiratory alkalosis occurs when excessive CO2 is exhaled, leading to an elevated pH and a low PaCO2. Although the PaCO2 is low (30 mmHg), which could suggest respiratory alkalosis, the bicarbonate (HCO3) is low at 18 mEq/L, not high as would be expected in a fully compensated respiratory alkalosis. In a fully compensated state, the pH would be normal (around 7.4), and there would be compensatory changes in both the bicarbonate and PaCO2. Since the bicarbonate is low and the pH is not at normal levels, this diagnosis is not appropriate.

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The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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