Chapter 44: Care of Patients with Problems of the Peripheral Nervous System Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman

Test Bank Medical Surgical Nursing 9th Edition Ignatavicius Workman MULTIPLE CHOICE 1. A client is admitted with Guillain-Barr syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions ANS: C Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation. DIF: Applying/Application REF: 914 KEY: Peripheral nervous system| respiratory assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 2. The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission ANS: D Demyelination leads to slowed nerve impulse transmission. The other options are not correct. DIF: Remembering/Knowledge REF: 913 KEY: Peripheral nervous system MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown ANS: C Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem. DIF: Analyzing/Analysis REF: 913 KEY: Peripheral nervous system| respiratory system MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important? a. Administering anxiolytics b. Having a ventilator nearby c. Obtaining atropine sulfate d. Sedating the client