The nurse is caring for a patient with a new diagnosis of Guillian-Barré syndrome. What does the nurse expect to find when assessing this patient?
Increased muscle weakness
Pronounced muscle atrophy
Diminished visual acuity
Impaired cognitive reasoning
The Correct Answer is A
A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.
B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.
C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.
D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings
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Correct Answer is ["A","C","D"]
Explanation
A) Include the student and family in a meeting to elicit her feelings about scoliosis and wearing a brace: This intervention is essential as it encourages open communication and allows the student to express her concerns and feelings about her condition and the brace. Involving the family ensures that they can provide support and understanding during this transition.
B) Suggest that the pediatrician prescribe an anti-anxiety agent for the student: While managing anxiety may be important, it is not the nurse's role to suggest medication without a thorough assessment and evaluation by a healthcare provider. This intervention may not be appropriate in the context of providing support for scoliosis.
C) Teach the student and family about clothing that will hide the brace: This intervention is practical and can help the student feel more comfortable and confident while wearing the brace. By discussing clothing options, the nurse can help alleviate some of the psychological stress associated with wearing a visible brace.
D) Provide contact information for a local scoliosis support group to the student and family: Connecting the family with a support group can provide valuable resources and emotional support. It allows them to engage with others who understand their experiences, which can be reassuring and help them navigate the challenges of scoliosis.
Correct Answer is B
Explanation
A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.
B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.
C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.
D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.