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A client suspected of having Guillain-Barre’ Syndrome has had a lumbar puncture.  When reviewing the laboratory results, what assessment data will be significant to this diagnosis?

The nurse is preparing to administer edrophonium chloride (Tensilon) to test a client.  Before this drug is administered the nurse will request which antidote be available?

Placing the client in the supine position, flexing the head towards the chest, eliciting flexion of the neck, what is the appropriate documentation for the client that displays adduction and flexion of the lower extremities?

The nurse is preparing a client who is scheduled to have a lumbar puncture.  What is the priority nursing action for this client?

What assessment data is appropriate to document in the clients electronic health record when utilizing the Glasgow Coma Scale to complete the neurological assessment?  Select ALL that apply.

The nurse conducts a home visit on 68-year-old male client with Parkinson’s disease following a recent fall 3 days after discharge from an acute care setting. Nurses’ Notes   1000 – Initial post-discharge visit in the client’s home. Met with client and his son. The client has moderate stage Parkinson’s disease and lives with his adult son, who works full-time and provides supportive care. Client reports that he fell on the stairs, attempting to use the second-floor bathroom. Assessment findings: Client is alert and oriented to person, place and time Walks short distances using a walker without problem, but reports that he tires easily Resting tremors noted in both arms and legs Son reports client needs assistance with ADLs on days when rigidity is worse Client reports that he has not slept more than 2 hours per night since discharge   1100 – After a short rest, continued assessment. Blood pressure sitting 138/88, standing 116/60, complains of dizziness on standing Heart rate 86 beats per minute and regular Respirations 16 per minute and unlabored; breath sounds clear bilaterally Temperature 97.2F (36.2C) Strength in legs is diminished bilaterally, but client is able to bear weight using walker Range of motion is within normal limits but rigid in all extremities Client reports frequent urination, “I am sometimes unable to make it to the bathroom” Speech is slow and halted, but understandable Moderate, continuous drooling noted Medications     Lisinopril once daily for hypertension Carbidopa/levodopa 3 times daily to treat Parkinson’s symptoms Environmental Assessment   Environmental assessment completed by walking through the home with the client. Client reports spending most of his time on the ground floor, aside from the need for toileting (bathroom is on the second floor with stair access). Floors are wood with no noted throw rugs. Walkways are clear of debris.    The nurse provides education for on-going care to the client and son. *What is priority for the nurse to include in her teaching. Select the best answer.

The client has been diagnosed with Guillain Barre´ Syndrome.  What assessment indicates the client is having clinical manifestations of this disease process?

A client is brought into the emergency department in the midst of a seizure.  The client has a history of status epilepticus and diabetes mellitus.  After being placed on the bed the seizure ceases, what will be the nurse’s priority intervention?

The nurse is providing care for the client experiencing aphasia. Which of the following nursing interventions are appropriate? Select all that apply.

The nurse is preparing a pamphlet to educate client’s on the risk factors  for a stroke. Which of the following statements will be placed on this educational material? Select all that apply.