You are developing a plan of care for a patient with Guillain-Barré syndrome. What nursing intervention would you know that would receive priority for this patient?
A) Using the incentive spirometer as prescribed
B) Maintaining the patient on bed rest
C) Assisting the patient with activities of daily living
D) Determining abnormalities of cognitive function
Ans: A
Feedback: Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions towards enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or level of consciousness. Assisting the patient with activities of daily living would be important, but would not be the priority nursing intervention.
You might also like to view...
After the loss of her infant, a woman tells the nurse that her husband didn't cry and hasn't expressed any sadness. She feels he never really wanted this baby. The most appropriate nursing response is,
a. "Men are unable to express their feelings." b. "Are you having marital difficulties?" c. "Each person mourns in his own way and according to his own timetable." d. "You ought to confront him and see what his real feelings are."
A pregnant patient is concerned about a sharp pain that is felt in the lower abdomen when making a quick move. What action should the nurse take to help this patient?
A) Assess when the patient's last bowel movement occurred. B) Explain that the sharp pain is tension on a uterine ligament. C) Notify the physician because of manifestations of appendicitis. D) Instruct that the pain is a pulled muscle and a heating pad will help.
Which assessment findings should the nurse use to differentiate between placenta previa and abruptio placentae?
A) Bleeding amount and consistency B) Uterine tone and contractions of the uterus C) Low back pain D) Shape of the abdomen
Information and communications technology is essential to nursing practice to: a. support development and disseminate newknowledge
b. support and empower an individual's decisionmaking and healthcare choices. c. a and b. d. none of the above.