A patient with Guillain-Barré syndrome is being assessed by the nurse. What clinical manifestation would alert the nurse that the patient's status is deteriorating?
A) Tidal volume of 500 mL
B) Residual lung volume of 1200 mL
C) Vital capacity of 11 mL/kg
D) Oxygen saturation of 97%
Ans: C
Feedback: A vital capacity of 12 to 15 mL/kg in a patient with Guillain-Barré syndrome would mean that the patient's condition has deteriorated to the point that mechanical ventilation may be needed. The tidal volume, residual lung volume, and oxygen saturation are within normal values. Breathing in a Guillain-Barré patient would become increasingly labored as the paralysis ascended towards the intercostals and diaphragm.
You might also like to view...
The nurse assesses her client to have mild anxiety concerning the birth process. The client states that she is not interested in Lamaze classes because she is single, and does not want to have natural childbirth
The nurse's best response would be: 1. "Lamaze classes promise painless childbirth. If you learn their methods, your pain is minimal." 2. "Lamaze classes can teach you relaxation methods, and also the benefits and risks of pain-relief methods. This assists you in making the best decision for you." 3. "You are very nervous. I think these classes would be best for you." 4. "Lamaze classes are geared toward couples. You might want to find a different class."
A physician asks a nurse to witness a consent form the patient has already signed, even though the nurse did not see the patient sign the form. The best action by the nurse is to
a. ask the patient if the signature on the form is his or hers. b. refuse because the nurse did not witness the signing. c. tell the physician the consent cannot be witnessed now. d. write "consent procedure witnessed" on the consent.
Which of the following is a biological explanation for gender differences in health status?
a. Influence of hormones b. Different treatment by parents c. Random differences in genetic inheritance d. Social expectations of appropriate gender behavior
Explanation: 1. Polypharmacy is a major factor in hospital readmission rates due to unnecessary adverse events. The nurse teaches ways in which the client can avoid readmission to the hospital, including how to take medications as prescribed. 2. There is not enough information to determine if the client is prone to missing medication doses. The nurse does suggest ways in which the client can
keep the medications and doses on a regular schedule, such as using a pill planner. 3. Although the client may have multiple conditions that warrant the medications prescribed, it is the job of each provider to obtain a thorough history. Additionally, pharmacists should alert the client and provider to any interaction potentials. 4. Cognitive impairments do occur when clients are on numerous medications. The nurse ensures the client understands their medication regimen and side effect management. 1. Dexamethasone 2. Ketorolac 3. Fluconazole 4. Phenobarbital 5. Atenolol