Hesi Case Studies–medical/surgical-guillain Barre Syndrome (amid Haq) Test Questions – Flashcards
Unlock all answers in this set
Unlock answersquestion
1. Which question should the nurse ask Amid to support the diagnosis of Guillain-Barre syndrome?
answer
Have you had any type of cold or stomach flu in the last month?
question
2. Which assessment intervention will the nurse implement specifically for the diagnosis or Guillain-Barre syndrome?
answer
Assess deep tendon reflexes
question
3. What intervention will the nurse implement prior to this procedure?
answer
Obtain informed consent
question
4. Which intervention should the nurse implement post-procedure?
answer
Increase Amid's fluid intake
question
5. Which action indicates the nurse understands Muslim food and beverage preferences?
answer
Notify the dietary department that Amid cannot eat any pork.
question
6. Which statement by Amid reflects the Muslim faith?
answer
I must be able to pray 5 times a day
question
7. What action should the nurse implement?
answer
Notify the healthcare provider immediately to clarify the prescription
question
8. How should the nurse respond?
answer
"He has muscle weakness that is traveling up his body and may get worse."
question
9. Which nursing diagnosis will take priority for Amid as the syndrome progresses?
answer
Ineffective breathing pattern related to progressive muscle weakness
question
10. Which long-term goal is written for this nursing diagnosis?
answer
The client will have minimal muscle atrophy
question
11. Which intervention should the Intensive Care Department nurse implement first?
answer
Assess the respiratory status and pulse oximeter reading
question
12. Which intervention addressing the mechanical ventilator should be included in the nursing care plan?
answer
Alternate the position of the endotracheal (ET) tube in the mouth daily.
question
13. Which action should the nurse implement?
answer
Acknowledge the wife's fears and explain about the ventilator and machines
question
14. Which statement is the nurse's best response?
answer
"I will ask yes or no questions and he can blink once for no and twice for yes."
question
15. List the order of interventions the nurse should implement (Place in numerical order from first action through last action.)
answer
1. Ventilate with manual resuscitation bag 2. Notify the respiratory therapist 3. Request stat arterial blood gases 4. Auscultate the client's lung sounds
question
16. Based on evaluation of the ABG results, which action will the nurse implement?
answer
Continue to monitor Amid without taking any actions
question
17. Which intervention will the nurse implement first?
answer
Check the tubing for any kinks
question
18. How should the nurse respond?
answer
"If the tube stays in his mouth too long it may injure his vocal cords."
question
19. Which intervention will the nurse implement when providing tracheostomy care for Amid?
answer
Position the ventilator tubing to ensure minimal pulling on the tube
question
20. Which assessment data would indicate the client is experiencing a complication secondary to the ventilator?
answer
The client has asymmetrical chest expansion
question
21. Which action will the nurse implement?
answer
Provide praise for performing the bath safely for Amid and the UAP
question
22. Which nursing task(s) can be safely delegated to the (UAP)? (Select all)
answer
-Escort a client in a wheel chair to the hospital patio area -Take vital signs on an elderly client recovering from hip replacement surgery
question
23. The nurse's response will be based on which scientific rationale?
answer
Full recovery usually occurs within several months to a year after onset of symptoms
question
24. Which referral is most important for the rehabilitation nurse case manager to implement initially upon Amid's transfer to the rehab unit?
answer
Physical therapist
question
25. Which intervention should the nurse implement prior to Amid's discharge from the rehabilitation unit?
answer
Demonstrate proper body mechanics to Amid's wife and brother
question
26. What is the best response by the nurse?
answer
"A visit to the mosque would be just fine; I know your faith is important."
