You Selected: • Have a family member assist with feeding at mealtimes. Correct response: • Assist the client in learning to eat with the left hand. Explanation: It is important to involve the client in care. The client will need to learn to eat with the non-dominant hand. Promoting independence and supporting attainment of this skill will help the client positively meet the goal of rehabilitation. Feeding the client or having the family feed the client does not promote independence. The client is not having difficulty chewing or swallowing, so a thickened liquid diet is not needed. Question 46 Which of the following nursing actions addresses the primary concern for a client with Guillain-Barré syndrome? You Selected: • Preparing for mechanical ventilation Correct response: • Preparing for mechanical ventilation Explanation: As this disease progresses, the nurse can expect the client to have weakness and possible paralysis of the diaphragm. This may lead to respiratory failure and require mechanical ventilation. This is the primary concern for the client. The other issues are not as high a priority as maintaining a patent airway. Question 47 A client recovering from Guillain Barré syndrome states, “I'm nervous that this disease will come back.” Which nursing diagnoses is most suggested by this comment? You Selected: • Anxiety Correct response: • Anxiety Explanation: Most clients with Guillain Barré syndrome recover completely, but anxiety is a common emotion. There is no indication that this client is denying that he or she has the disease. Anticipatory grief can occur before a loss. Risk for impaired breathing is a characteristic of Guillain Barré but does not address the client’s fear. Question 48 A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? You Selected: • Impaired verbal communication Correct response:
• Risk for injury Explanation: Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow’s hierarchy of needs. Question 49 The nurse is caring for a client who has been placed on phenobarbital 30 mg daily for newly diagnosed seizure activity. Which instruction would be included in client teaching specifically related to anticonvulsant drug efficacy? You Selected: • Maintain a seizure frequency chart. Correct response: • Maintain a seizure frequency chart.
You've reached the end of your free preview.
Want to read all 9 pages?
- Spring '17
- mrs. Vargovich
- Nursing, Intracranial pressure, Traumatic brain injury, Cerebrospinal fluid, Correct Response