The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which of the fol-lowing acid-base imbalances?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
3
Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore "metabolic acidosis," "metabolic alkalosis," and "respiratory alkalosis" are incorrect.
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A patient becomes flaccid with fixed and dilated pupils. The patient's ICP falls from 65 to 12 mm Hg. What should the nurse suspect is happening?
a. The patient is having a seizure. b. The patient's brain has herniated. c. The patient's cerebral edema is resolving. d. The patient is excessively dehydrated from the mannitol.
The nurse is performing a psychosocial assessment, and asks the client to interpret a proverb, such as "slow and steady wins the race." The nurse should use the client's response to evaluate the client's:
1. memory recall. 2. ability to think abstractly. 3. ability to problem-solve. 4. judgment skills.
Qualitative research, in comparison to quantitative research, aims to?
a. Establish cause and effect of relationships b. Explore the depth, richness and complexity in a phenomena c. Focuses on a small number of specific concepts d. Uses language in a way that implies neutrality
The wife of a patient who recently returned from a radical neck dissection asks a nurse why her husband was given scopolamine. The best response by the nurse is:
1. "It is important to dry secretions to reduce the bacteria in his saliva." 2. "Swallowing is painful for him right now. Scopolamine helps keep him from drooling." 3. "This medication will reduce the swelling in his lips and tongue by reducing the amount of saliva that his body makes." 4. "The scopolamine will help dry oral secretions to reduce his chances of aspirating saliva into his lungs."