The nurse working in the Neuro ICU is caring for a client with Guillain Barre Syndrome. Which of the following activities would be best assigned to the Licensed practical nurse (LPN)?

Begin initial discharge teaching on home care activities

Begin administration of red blood cells

Reassess the clients mobility in the upper extremity

Administration of morphine for pain

Answer and Explanation

The Correct Answer is D

A) Begin initial discharge teaching on home care activities:
While discharge teaching is a vital part of the care process, it is typically an activity assigned to a registered nurse (RN) because it involves comprehensive patient education on topics such as medication management, follow-up care, and recognizing signs of complications. Guillain-Barré syndrome (GBS) often requires intensive care in the acute phase, and the RN is responsible for evaluating the client’s readiness for discharge and ensuring they fully understand the care required at home

B) Begin administration of red blood cells:
Administering blood products, such as red blood cells, requires close monitoring for potential reactions, and it is typically the responsibility of the RN. The RN must assess the client’s baseline status, monitor for transfusion reactions, and adjust care accordingly during the procedure. This task requires a higher level of clinical judgment and nursing knowledge than an LPN.

C) Reassess the client's mobility in the upper extremity:
Reassessing a client’s mobility, especially in a neurological condition like Guillain-Barré syndrome, requires detailed and ongoing assessment to determine changes in the patient’s strength, motor function, and overall neurological status. This activity is a more complex task that requires a registered nurse's clinical expertise.

D) Administration of morphine for pain:
The administration of pain medications, including morphine, can be appropriately assigned to the LPN under the supervision of an RN. The LPN is trained to administer medications and monitor for common side effects such as respiratory depression, especially in clients who may be at risk due to their neurological condition. However, it is essential for the LPN to communicate with the RN and report any significant changes in the client’s condition during pain management.

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Correct Answer is ["B","C","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

A. Barrel chest B. Increased fatigue C. Respiratory rate 40bpm D. Thin appearance

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Assessment findings	Expected Findings	Findings to be reported to provider
Barrel chest	✔️
Increased fatigue		✔️
Respiratory rate 40bpm		✔️
Thin appearance	✔️

Barrel chest: Expected Finding

Increased fatigue: Finding to be reported to the provider

Respiratory rate 40 bpm: Finding to be reported to the provider

Thin appearance: Expected Finding

Rationales:

Barrel chest – Expected Finding:

A barrel chest is a common physical finding in clients with chronic obstructive pulmonary disease (COPD), especially emphysema. It results from hyperinflation of the lungs over time, altering the shape of the chest wall.

Increased fatigue – Finding to be reported to the provider:

While COPD clients often experience fatigue, a sudden or unusual increase in fatigue may indicate worsening respiratory function or exacerbation of the disease. This finding requires further assessment and possible intervention to prevent complications.

Respiratory rate 40 bpm – Finding to be reported to the provider:

A respiratory rate of 40 bpm indicates significant tachypnea and respiratory distress. This finding, coupled with accessory muscle use, suggests the client may be experiencing an acute exacerbation of COPD or impending respiratory failure, which requires immediate provider notification.

Thin appearance – Expected Finding:

Clients with COPD often have a thin or cachectic appearance due to increased energy expenditure for breathing and reduced caloric intake. This is a typical finding in advanced COPD and does not require urgent reporting unless accompanied by other concerning symptoms.

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The nurse working in the Neuro ICU is caring for a client with Guillain Barre Syndrome. Which of the following activities would be best assigned to the Licensed practical nurse (LPN)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

Correct Answer is ["B","C","D"]

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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