While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Profuse sweating.

Weakness in the lower legs.

Loss of sensation at T-8.

Leg pain that worsens at night.

Answer and Explanation

The Correct Answer is C

Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.

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Correct Answer is ["A","D","E"]

Explanation

Furosemide is a loop diuretic used to treat fluid retention and high blood pressure by increasing the amount of urine the body makes. Therefore, assessing urinary output is crucial to determine the patient’s response to treatment. Lung sounds and oxygen saturation should also be assessed as furosemide is often used to treat edema caused by heart failure. Improved lung sounds and oxygen saturation can indicate a reduction in fluid buildup in the lungs.

A. Eat a diet that is high in protein and vitamins A and C. B. Maintain bed rest as much as possible. C. Keep legs elevated when sitting or lying down. D. Inspect ankles daily for areas of darkening skin. E. Apply intermittent cold compresses four times daily.

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

Explanation

Choice A rationale
Eating a diet that is high in protein and vitamins A and C is beneficial for wound healing. Protein is essential for tissue repair, while vitamins A and C play a crucial role in collagen synthesis, which is vital for wound healing.
Choice B rationale
Maintaining bed rest as much as possible is not the best advice for a patient with venous leg ulcers. Mobility improves blood circulation, which can aid in the healing of the ulcers.
Choice C rationale
Keeping legs elevated when sitting or lying down can help reduce swelling and improve blood flow, which can promote healing of the ulcers.
Choice D rationale
Inspecting ankles daily for areas of darkening skin is important as it can help in early detection of any potential complications or worsening of the condition.
Choice E rationale
Applying intermittent cold compresses four times daily is not typically recommended for venous leg ulcers. The standard treatment involves cleaning and dressing the wound, using compression therapy, and in some cases, taking prescribed medications.

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While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan? (Select all that apply.)

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

Explanation

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

The nurse is educating a client, who was admitted with a blood glucose level of 580 mg/dL, on how to prevent complications related to diabetes mellitus. Which statement made by the client indicates they have understood the information?

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment?

A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?