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 C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

A. "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication." B. "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function." C. "Before you lose cognitive function, you should consider creating an advanced directive." D. "Despite severe symptoms right now, most patients recover with treatment."

Correct Answer is B

Explanation

A) "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication."
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in the progressive loss of motor neurons, which leads to muscle weakness, atrophy, and paralysis. It is not caused by "excess chemicals in the brain," and there are currently no medications that can cure ALS or completely control its symptoms. Medications such as riluzole can slow the progression slightly, but they do not stop or reverse the disease.

B) "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function."
ALS is indeed a progressive neurodegenerative disease that leads to the gradual loss of muscle function due to the death of motor neurons. Over time, the patient will experience muscle weakness, atrophy, and paralysis, while the cognitive function typically remains intact until the later stages of the disease, although some patients may develop frontotemporal dementia. it is essential for the patient to understand that the disease will progressively impair their physical abilities while leaving cognitive functions largely unaffected in most cases.

C) "Before you lose cognitive function, you should consider creating an advanced directive."
While it is important for individuals with ALS to plan for the future, this statement is not entirely accurate. Cognitive function in ALS is often preserved throughout most of the disease, although there is a subset of patients who may develop frontotemporal dementia. It would be more appropriate to discuss advanced directives early in the disease, but it is not guaranteed that cognitive function will be lost before physical decline.

D) "Despite severe symptoms right now, most patients recover with treatment."
ALS is a progressive disease with no cure, and it does not typically result in recovery. While certain treatments can help manage symptoms or slow the progression of the disease, recovery is not a realistic expectation. Most patients with ALS experience gradual worsening of symptoms and ultimately may require assistance with daily activities as the disease progresses.

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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

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