Guillain Barre Case Study 96y12
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Guillain-Barré syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It affects the peripheral nervous system and results in loss of myelin and edema and inflammation of the affected nerves, causing a loss of neurotransmission to the periphery. The nurse on the medical floor is completing the ission assessment. The client tells the nurse that at first his feet were numb but now his entire legs are numb from his thighs down to his toes.
1. Which question should the nurse ask Amid to the diagnosis of Guillain-Barré syndrome? A) "Were you exposed to anyone with this syndrome prior to coming to the U.S.?" INCORRECT This syndrome is not a contagious or communicable disease. B) "Have you had any type of cold or stomach virus in the last month?" CORRECT This syndrome is usually preceded by a respiratory or gastrointestinal infection 1 to 4 weeks prior to the onset of neurologic deficits. C) "Did you receive immunizations prior to coming to the United States?" INCORRECT This syndrome is not a complication of any immunization. There is no immunization to prevent Guillain-Barré syndrome. D) "Do you take any prescription or over the counter medications?" INCORRECT While this question should be included in every ission interview, it will not provide information to help the diagnosis of Guillain-Barré syndrome. Points Earned:
1.0/1.0
Correct Answer(s): B
The etiology of this disorder is unknown, but it is believed to be a cell-mediated immunologic reaction directed at the peripheral nerves. The syndrome is often preceded by immune system stimulation from a viral infection, trauma, surgery, viral immunizations, human immunodeficiency virus (HIV), or lymphoproliferative neoplasms. The nurse continues to conduct the ission assessment for Amid.
2. Which assessment intervention will the nurse implement specifically for the diagnosis of GuillainBarré syndrome? A) Assess deep tendon reflexes. CORRECT
Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. The paralysis ascends up the lower extremities. B) Obtain a sterile urine specimen. INCORRECT A urinalysis is not a specific assessment intervention for this syndrome. C) Determine the glucose level. INCORRECT A blood glucose level is not a specific assessment intervention for this syndrome. D) Take Amid's vital signs. INCORRECT Vital signs are a part of any ission assessment but are not a specific assessment intervention for this syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Diagnostic Test: Lumbar Puncture
Diagnosis is based primarily on the patient's history and clinical signs. Cerebrospinal fluid (CSF) is normal or has a low protein content initially, but after 7 to 10 days it shows an elevated protein level to 700 mg/dl (7 g/L) (normal protein is 15 to 45 mg/dl [0.15 to 0.45 g/L]) with a normal cell count. The healthcare provider schedules Amid for a lumbar puncture for a (CSF) analysis to confirm the diagnosis of Guillain-Barré syndrome.
3. Which intervention will the nurse implement prior to this procedure? A) Keep Amid NPO. INCORRECT Amid does not need to be NPO prior to this procedure. B) Instruct Amid not to void. INCORRECT Amid should void prior to this procedure to help prevent accidental puncture of the bladder during procedure. C) Obtain informed consent. CORRECT Amid is alert and oriented and has not received any pain medication, therefore, he is capable of g the consent form allowing this invasive procedure.
D) Place a saline lock in the hand. INCORRECT A lumbar puncture does not require a saline lock insertion for the procedure. Points Earned:
1.0/1.0
Correct Answer(s): C
The healthcare provider performs the lumbar puncture at Amid's bedside.
4. Which intervention should the nurse implement postprocedure? A) Keep Amid in a side-lying position. INCORRECT Amid should lie prone or supine for 3-4 hours after the procedure to help reduce leakage of the CSF. B) Apply pressure to the puncture site. INCORRECT A band-aid is placed over the puncture site and pressure does not need to be applied to the site. C) Assess Amid's brachial pulses. INCORRECT The nurse should complete a neuromuscular assessment of the lower extremities rather than the upper extremities. D) Increase Amid's fluid intake. CORRECT Increased fluid intake helps prevent a post-procedure headache which may occur after a lumbar puncture. The healthcare provider confirms the diagnosis of Guillain-Barré syndrome and discusses this with Amid but his family is not in the room. Points Earned:
1.0/1.0
Correct Answer(s): D
Cultural/Spiritual Needs
The nurse obtains additional assessment data and plans care related to Amid's cultural needs.
5. Which action indicates the nurse understands Muslim food and beverage preferences?
A) Allow Amid to have one glass of red wine to relax in the evening. INCORRECT Muslims do not believe in drinking alcohol. B) Instruct Amid's family that they will need to meet Amid's dietary needs. INCORRECT The family can bring specific dishes/foods, but the hospital must provide Amid with meals that acknowledge his cultural dietary restrictions. The family is not responsible for providing Amid's nutritional needs. C) Notify the dietary department that Amid cannot eat any pork. CORRECT The Muslim faith prohibits eating any type of pork. D) Help Amid select menu items that do not contain any dairy products. INCORRECT The Muslim faith has food/beverage preferences that the nurse should respect, but avoiding dairy products is not one of the restrictions in the Muslim faith. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse asks Amid, "How can the healthcare team best your Muslim faith while you are in the hospital?"
6. Which statement by Amid reflects the Muslim faith? A) "I must be able to pray five times a day." CORRECT The Muslim faith teaches its followers to pray five times a day facing toward Mecca. B) "If I die, please face me toward the sun." INCORRECT After death, a Muslim's face must be toward Mecca (northeast) rather than toward the sun. C) "My wife must cleanse my body if I should die." INCORRECT After death, the clothes must be removed and the body cleansed by a person of the same gender. D) "I must fast tomorrow because it will be Friday." INCORRECT Friday is the holy day for the Muslim faith, but fasting is not part of the Muslim faith. Points Earned:
0.0/1.0
Correct Answer(s): A
Legal Issues
The nurse is transcribing the healthcare provider's itting prescriptions. The nurse is having difficulty reading one of the prescriptions.
7. Which action should the nurse implement? A) Implement the prescription as fully as possible based on its legibility. INCORRECT This action increases the risk for a medication error. B) the director of nurses to help understand the prescription. INCORRECT It is not the responsibility of the director of nurses to interpret illegible prescriptions. C) the prescription during the healthcare provider's routine rounds. INCORRECT This delays the implementation of the prescriptions. D) Notify the healthcare provider immediately to clarify the prescription. CORRECT If the nurse is unable to clearly read and understand the healthcare provider's prescription, it must be clarified immediately with the person who wrote the prescription. Points Earned:
1.0/1.0
Correct Answer(s): D
Later during the shift, the nurse enters Amid's room and meets Amid's brother and his wife, who is in traditional Muslim dress with her face covered. Amid's brother states, "Amid tells me he has a syndrome but can't explain to me what is going on, can you tell me what is wrong with my brother?"
8. How should the nurse respond? A) "According to the privacy law, I cannot discuss this information with you." INCORRECT This response is not a correct interpretation of HIPPA regulations. B) "I will Mr. Haq's healthcare provider so that he can explain it to you." INCORRECT
The nurse can discuss Guillain-Barré syndrome with the client and his family. C) "I can discuss Amid's condition with his wife but not with you in the room." INCORRECT The nurse does not understand the HIPPA rules and regulations when making this statement. D) "He has muscle weakness that is traveling up his body and may get worse." CORRECT Amid's presence in the room can be understood by the nurse as implied consent. Therefore, the nurse can answer the brother's questions and give factual information that is understood by laypersons. Points Earned:
1.0/1.0
Correct Answer(s): D
Nursing Diagnosis
The nurse on the medical floor is developing a plan of care for Amid, based on the expected clinical pathway of the syndrome.
9. Which nursing diagnosis will take priority for Amid as the syndrome progresses? A) High risk for injury related to inability to ambulate and transfer safely. INCORRECT Safety is an important issue for Amid, but this is not the highest priority nursing diagnosis. B) Fear and anxiety related to hospitalization and loss of control. INCORRECT Amid's psychological needs are important, but psychosocial problems are of less priority than another diagnosis. C) Altered nutrition, less than body requirements, related to inability to swallow. INCORRECT Amid has had choking episodes and is at risk for inability to swallow due to the disease process, but this is not the highest priority nursing diagnosis. D) Ineffective breathing pattern related to progressive muscle weakness. CORRECT Guillain-Barré syndrome causes ascending paralysis that will cause respiratory failure. Therefore, the diagnosis of ineffective breathing pattern will take priority during the course of the syndrome. Maslow's Hierarchy of Needs. Points Earned:
1.0/1.0
Correct Answer(s): D
The nurse includes the nursing diagnosis, "Impaired physical mobility related to paralysis" in the plan of care.
10. Which long term goal is written for this nursing diagnosis? A) The client will have no skin breakdown or irritation. INCORRECT This is indicated for the nursing diagnosis, "risk for impaired skin breakdown." B) The client will have minimal muscle atrophy. CORRECT A client with Guillain-Barré syndrome will not be able to move the extremities during the course of the syndrome. Therefore, preventing muscle atrophy is an appropriate long term goal. C) The client will perform active range of motion exercises. INCORRECT The client will not be able to move the extremities. Therefore, the nurse will have to perform ive range of motion exercises. D) The client will be turned every 2 hours while awake. INCORRECT This is a nursing intervention rather than a goal. Additionally, the client should also be turned while he is sleeping, unless he is on a special immobility bed. Points Earned:
1.0/1.0
Correct Answer(s): B
Ventilator Care
Two days after ission, Amid starts complaining of difficulty breathing. His numbness is ascending up his body and affecting his respiratory muscles. He is transferred to the Intensive Care Department and placed on a ventilator for respiratory . Assessment of the patient is the most important aspect of nursing care during the acute phase. The nurse must monitor the ascending paralysis; assess respiratory function; monitor arterial blood gases (ABGs); and assess the gag, corneal, and swallowing reflexes during the routine assessment. Reflexes are usually decreased or absent.
11. Which intervention will the Intensive Care Department nurse implement first? A) Confirm that the ventilator settings are correct. INCORRECT Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is important, but this is not the first intervention the nurse should implement.
B) that ventilator alarms are functioning properly. INCORRECT Making sure alarms are functioning properly is important, but another action is of higher priority. C) Assess the respiratory status and pulse oximeter reading. CORRECT Assessment is the first step of the nursing process and is the first action the nurse should implement when caring for a client on a ventilator. D) Monitor Amid's arterial blood gas results. INCORRECT Monitoring lab results is an important intervention for the client on a ventilator, but is not the priority intervention. Points Earned:
1.0/1.0
Correct Answer(s): C
12. Which intervention addressing the mechanical ventilator should be included in the nursing care plan? A) Alternate the position of the endotracheal (ET) tube in the mouth daily. CORRECT Alternating the ET tube will help prevent the development of a pressure ulcer on the client's tongue. B) Obtain a chest x-ray daily to determine correct position of the ET tube. INCORRECT A CXR is done immediately after insertion of the ET tube, but the nurse must check the lip line daily to determine position of the ET tube rather than obtaining a daily CXR. C) Check daily to ensure that the client's endotracheal cuff is deflated. INCORRECT The cuff should be inflated with no more than 25 cm H2O to ensure there is no air leakage, and must be checked every 4 to 8 hours, not daily. D) Ensure that 3 fingers can be inserted under the ties securing the ET tube. INCORRECT The ties should be snug but not too tight, usually inserting one finger under the tie is sufficient. Points Earned:
0.0/1.0
Correct Answer(s): A
Communication Skills
After Amid is settled and resting comfortably in the Intensive Care Department, the nurse escorts Amid's wife and brother into his room. Amid's eyes are open and he is aware of what is going on around him. Amid's wife starts crying uncontrollably which causes Amid to start fighting the ventilator and crying as well.
13. Which action should the nurse implement? A) Tell the wife she must stop crying or she will not be able to visit again. INCORRECT This action does not address the fears of Amid's wife. Additionally, preventing her from visiting will not meet Amid's or his wife's psychosocial needs. B) Escort Amid's wife out of the room and back to the waiting area. INCORRECT This action does not address the fears of Amid's wife. C) Medicate Amid immediately so that he will quit fighting the ventilator. INCORRECT This action does not address the fears of Amid's wife. D) Acknowledge the wife's fears and explain about the ventilator and machines. CORRECT This is a frightening situation and environment, so the nurse should acknowledge the wife's fears, and spend time explaining all the machines as well as the intensive care environment. Seeing that his wife's fears are respected and that she is cared for is likely to be the most effective measure to reduce Amid's anxiety and help him relax. Points Earned:
1.0/1.0
Correct Answer(s): D
After Amid quits fighting the ventilator, Amid's brother asks the nurse, "How will you communicate with my brother?"
14. Which statement is the nurse's best response?
A) "He will write what he needs on an erase slate board kept at the bedside." INCORRECT The ascending paralysis has reached his respiratory muscles. Therefore, Amid will not be able to use his hands to write. B) "I will ask yes/no questions and he can blink once for no and twice for yes." CORRECT Amid will not be able to use his arms due to the paralysis but he can blink his eyes.
C) "A speech therapist will help us communicate with your brother." INCORRECT A speech therapist will not be able to help Amid communicate while he is on the ventilator. D) "We will make sure the call light is available if he needs to call us." INCORRECT The ascending paralysis has reached his respiratory muscles. Therefore, Amid will not be able to use his hands to push the call light. Points Earned:
1.0/1.0
Correct Answer(s): B
A communication system must be established with the use of the patient's available abilities. This is extremely difficult if the disease progresses to involvement of the critical nerves. At the peak of a severe episode the patient may be incapable of communicating. The nurse must explain all procedures before doing them and reassure the patient that muscle function will return.
A Complication Occurs
During the night shift, Amid starts having difficulty breathing. The nurse checks the ventilator and realizes something is wrong but is unable to fix the problem. Amid is in obvious acute respiratory distress.
15. Which intervention should the nurse implement first? A) Notify the respiratory therapist immediately. INCORRECT The nurse must first address Amid's acute respiratory distress and then notification of other departments can be done. B) Ventilate with a manual resuscitation bag. CORRECT If the ventilator system malfunctions the nurse must ventilate the client with a manual resuscitation bag until the problem is resolved. C) Request stat arterial blood gases. INCORRECT The nurse must first address Amid's respiratory distress before requesting any laboratory data. D) Auscultate the client's lung sounds. INCORRECT
In some instances, assessment is not the priority. In this situation, the client is in "obvious acute respiratory distress," therefore the nurse should intervene without further assessment to help the client breathe. Points Earned:
1.0/1.0
Correct Answer(s): B
The respiratory therapist fixes the ventilator and Amid is placed back on the ventilator. The healthcare provider requests stat arterial blood gases (ABG). The ABG results are: pH 7.38, PaO 2 92, PaCO2 38, HCO3 24.
16. Based on evaluation of the ABG results, which action will the nurse implement? A) Continue to monitor Amid without taking any action. CORRECT These arterial blood gases are within normal limits, which means the manual resuscitation was performed correctly and no further action is required. B) Increase the FIO2 rate to 100% oxygen for 10 minutes. INCORRECT The client's oxygen rate does not need to be increased based on these ABG results. C) Suction the client immediately via the end line suction. INCORRECT These ABG results do not indicate that the client needs to be suctioned. D) Encourage the client to take slow deep breaths. INCORRECT The client is on a ventilator and is unable to independently take slow deep breaths. Points Earned:
0.0/1.0
Correct Answer(s): A
Two hours after Amid is placed back on the ventilator the machine alarm goes off and there is an increase in the peak airway pressure.
17. Which intervention will the nurse implement first? A) Check the tubing for any kinks. CORRECT When peak airway pressure is increased the nurse should implement the intervention that is least invasive for the client. This alarm may sound as the result of a plugged airway, "bucking" the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.
B) Suction the client's airway for secretions. INCORRECT The alarm may indicate the client needs suctioning but the nurse should always begin with the least invasive procedure when troubleshooting a ventilator alarm. C) Manually ventilate the client. INCORRECT This action may be needed, but it is not the first intervention. The client should not be removed from the ventilator unless no other option is available. D) Sedate the client with a muscle relaxant. INCORRECT This action may be needed, but the nurse should not sedate the client unless absolute necessary. Points Earned:
1.0/1.0
Correct Answer(s): A
Tracheostomy Placement
Ten days later Amid is still receiving mechanical ventilation via the endotracheal tube. The healthcare provider has determined that Amid will need a tracheostomy since it is not known how much longer he will require ventilator . Amid's brother asks, "Why does he need to have this procedure? Is he getting worse?"
18. How should the nurse respond? A) "We are not sure if your brother is getting worse, but he needs a trach." INCORRECT This is a vague answer. In addition, the tracheostomy is not planned because the client is getting worse. B) "Your brother will be able to talk with you after having this procedure." INCORRECT A tracheostomy byes the upper airway. Therefore, the client will not be able to talk. C) "If the tube stays in his mouth too long it may injure his vocal cords." CORRECT The endotracheal tube (ET) is placed through the vocal cords into the trachea and can cause damage if left in place too long; a client usually has an ET tube for 10 to 14 days. D) "The tracheostomy procedure will allow Amid to breathe more on his own." INCORRECT The ventilator will be connected to a tracheostomy tube instead of the endotracheal tube. There will be no difference in ability to breathe independently.
Points Earned:
1.0/1.0
Correct Answer(s): C
19. Which intervention will the nurse implement when providing tracheostomy care for Amid? A) Ensure that the low pressure tracheostomy cuff is deflated. INCORRECT The tracheostomy cuff must be inflated to prevent air leaks and tracheal aspiration while the client is on the ventilator. B) Remove the soiled twill tape before replacing the new twill tape. INCORRECT The nurse should place the new tape in place before removing the soiled tape to prevent the tracheostomy tube from being dislodged. C) Position the ventilator tubing to ensure minimal pulling on the tube. CORRECT This will reduce the risk of trauma to the trachea. D) Perform tracheostomy care daily, including removal of the inner cannula. INCORRECT Tracheostomy care should be performed at least every 8 hours to prevent infection. The inner cannula should not be removed because the client will have to be off the ventilator during the cleaning. Points Earned:
0.0/1.0
Correct Answer(s): C
The nurse is aware that Amid is at risk for complications secondary to being on the ventilator. The nurse performs frequent assessments of Amid.
20. Which assessment data would indicate the client is experiencing a complication secondary to the ventilator? A) The client's urine output is 100 ml in 2 hours. INCORRECT A urine output of 30 ml/hr indicates the kidneys are functioning properly. B) The pulse oximeter reading is greater than 95%. INCORRECT This indicates that the client is being adequately oxygenated. C) The client has asymmetrical chest expansion. CORRECT
Asymmetrical chest expansion indicates the client has had a pneumothroax which is a complication of ventilation. D) The telemetry shows occasional premature ventricular contractions. INCORRECT Occasional premature ventricular contractions occur in most clients and do not indicate a complication secondary to the ventilator. Fortunately, Amid does not experience any complications from the ventilator. Two weeks later, Amid's paralysis suddenly stops and starts descending as expected with Guillain-Barré syndrome. Amid is successfully weaned from the ventilator since his respiratory muscles are no longer paralyzed. Points Earned:
1.0/1.0
Correct Answer(s): C
Management Considerations
Amid is transferred to the medical floor. The unlicensed nursing personnel (UAP) is bathing the client with the bed in a high position with the opposite side rail raised.
21. Which action will the nurse implement? A) Demonstrate the correct technique when giving a bed bath. INCORRECT There is no need for the nurse to demonstrate this skill. B) Encourage the UAP to put the bed in the lowest position. INCORRECT The bed should be at a comfortable height for the UAP to bathe the client for best body mechanics. C) Instruct the UAP to get another person to help with the bath. INCORRECT The UAP can bathe a client without assistance, if the client's safety can be ensured. D) Provide praise for performing the bath safely for Amid and the UAP. CORRECT Raising the opposite side rail addresses Amid's safety to ensure that he will not fall out of bed while being turned. Having the bed in the high position is demonstrating proper body techniques by the UAP. Points Earned:
1.0/1.0
Correct Answer(s): D
The UAP and the nurse are caring for five clients including Amid for the 12-hour shift.
22. Which nursing task can the nurse safely delegate to the unlicensed assistive personnel (UAP)? A) Escort a client in a wheel chair to the hospital patio area. CORRECT The UAP may escort a client outside as long as the client is stable. B) Determine a client's ability to do range of motion exercises. INCORRECT Assessment cannot be delegated to a UAP. C) Help feed a client who has had multiple choking episodes. INCORRECT The nurse cannot delegate tasks for clients with unstable conditions, such as choking. D) Teach a client how to apply a gait belt before ambulating. INCORRECT The nurse cannot delegate teaching to a UAP. Points Earned:
1.0/1.0
Correct Answer(s): A
Rehabilitation Care
The nurse assesses Amid and performs bedtime care. Amid's wife asks the nurse, "How long before my husband is back to normal? I miss him so much."
23. The nurse's response will be based on which scientific rationale? A) Full recovery usually occurs within several months to a year after onset of symptoms. CORRECT This is the correct scientific rationale when answering the wife's question. B) Most clients with Guillain-Barré syndrome have some type of residual disability. INCORRECT Guillain-Barré syndrome results in permanent residual disability in about 10% of cases. C) The majority of clients with this syndrome end up on mechanical ventilation for life. INCORRECT This response indicates that the nurse does not understand the typical course for a client diagnosed with Guillain-Barré syndrome.
D) The rehabilitation phase is short and the client is fully recovered within a month. INCORRECT This response indicates that the nurse does not understand the typical course for a client diagnosed with Guillain-Barré syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Throughout the course of the illness, the nurse needs to provide and encouragement to the family and patient. Because residual problems and relapses are uncommon except in the chronic form of the disease, complete recovery can be anticipated although it is generally a slow process that takes months or years if axonal degeneration occurs. Amid continues to improve, is able to breathe without use of the ventilator, and is transferred to the rehabilitation unit with plans to be discharged to his brother's home within the next month.
24. Which referral is most important for the rehabilitation nurse case manager to implement initially upon his transfer to the rehab unit? A) Guillain-Barré Syndrome Foundation. INCORRECT This referral will be helpful to provide and additional information, but is not the most important referral upon arrival in the rehab unit. B) Physical therapist. CORRECT The physical therapist will help with gait training, muscle building, and transfer techniques. It is essential that this training be started as soon as the client is transferred to the rehab unit to promote early discharge and reduce the risk of injury. C) Hospital dietician. INCORRECT The client may benefit from dietary counseling to help build his strength. However, another referral is of higher priority. D) Home health care services. INCORRECT Early discharge planning will be beneficial; however, rehab typically will require at least a month, so another referral is of greater immediacy. Points Earned:
0.0/1.0
Correct Answer(s): B
Discharge
Amid works hard during rehabilitation and is able to ambulate with a walker or a cane. He gets tired easily and has regained some of his strength, but needs some assistance when getting out of the bed and chair. He has been in the rehabilitation unit for 1 month and is scheduled to be discharged to his brother's home in 2 days.
25. Which intervention should the nurse implement prior to Amid's discharge from the rehabilitation unit? A) Make a referral to the social worker to evaluate the home for safety. INCORRECT The occupational therapist will evaluate Amid's brother's home for safety, the social worker addresses financial or discharge concerns. B) Show Amid how to perform ive range of motion exercises. INCORRECT Amid must perform active range of motion exercises to regain his strength. No one should do them for him (ive). C) Arrange to have a Hoyer lift sent to Amid's brother's home. INCORRECT A Hoyer lift is used to transfer an immobile client from a bed to chair. Amid can transfer himself with assistance. D) Demonstrate proper body mechanics to Amid's wife and brother. CORRECT Since Amid is having difficulty getting out of the bed and chair his family should be taught correct techniques to help transfer Amid. This will help prevent injury to both Amid and his family . Points Earned:
0.0/1.0
Correct Answer(s): D
The day for Amid's discharge has finally arrived. The nurse escorts Amid, along with his wife and brother, to the car. Amid asks the nurse, "May I visit the mosque on my way home?"
26. What is the best response by the nurse? A) "I would recommend going straight home. You will be very tired." INCORRECT This response does not Amid's cultural needs.
B) "A visit to the mosque would be just fine; I know your faith is important." CORRECT Amid's Muslim faith is very strong, and visiting the mosque is important to him. He has not been able to visit in over 2 months and the nurse should his spiritual and cultural needs. C) "Your wife should probably decide if you should visit the mosque." INCORRECT Decision-making in the Muslim faith is typically the responsibility of the man. The nurse should allow the couple to adhere to their own style of decision-making, and respect their traditions, rather than offering the advice that the wife should make this decision. D) "Do you think you are strong enough to make a visit to the mosque?" INCORRECT If Amid is being discharged from the rehabilitation unit, he should be strong enough to visit the mosque and practice his faith. Points Earned:
1.0/1.0
Correct Answer(s): B
Case Outcome
Amid visits the mosque on the way home. He plans to stay with his brother for 2 more months then return to his home. He was referred to a home healthcare agency and will be receiving weekly visits from the home healthcare nurse and physical therapist. The rehabilitation team expects Amid to make a full recovery within the next year. The expected outcomes are that the patient with Guillain-Barré syndrome will:
return to usual level of physical functioning be free from pain and discomfort maintain nutritional status
1. Which question should the nurse ask Amid to the diagnosis of Guillain-Barré syndrome? A) "Were you exposed to anyone with this syndrome prior to coming to the U.S.?" INCORRECT This syndrome is not a contagious or communicable disease. B) "Have you had any type of cold or stomach virus in the last month?" CORRECT This syndrome is usually preceded by a respiratory or gastrointestinal infection 1 to 4 weeks prior to the onset of neurologic deficits. C) "Did you receive immunizations prior to coming to the United States?" INCORRECT This syndrome is not a complication of any immunization. There is no immunization to prevent Guillain-Barré syndrome. D) "Do you take any prescription or over the counter medications?" INCORRECT While this question should be included in every ission interview, it will not provide information to help the diagnosis of Guillain-Barré syndrome. Points Earned:
1.0/1.0
Correct Answer(s): B
The etiology of this disorder is unknown, but it is believed to be a cell-mediated immunologic reaction directed at the peripheral nerves. The syndrome is often preceded by immune system stimulation from a viral infection, trauma, surgery, viral immunizations, human immunodeficiency virus (HIV), or lymphoproliferative neoplasms. The nurse continues to conduct the ission assessment for Amid.
2. Which assessment intervention will the nurse implement specifically for the diagnosis of GuillainBarré syndrome? A) Assess deep tendon reflexes. CORRECT
Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. The paralysis ascends up the lower extremities. B) Obtain a sterile urine specimen. INCORRECT A urinalysis is not a specific assessment intervention for this syndrome. C) Determine the glucose level. INCORRECT A blood glucose level is not a specific assessment intervention for this syndrome. D) Take Amid's vital signs. INCORRECT Vital signs are a part of any ission assessment but are not a specific assessment intervention for this syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Diagnostic Test: Lumbar Puncture
Diagnosis is based primarily on the patient's history and clinical signs. Cerebrospinal fluid (CSF) is normal or has a low protein content initially, but after 7 to 10 days it shows an elevated protein level to 700 mg/dl (7 g/L) (normal protein is 15 to 45 mg/dl [0.15 to 0.45 g/L]) with a normal cell count. The healthcare provider schedules Amid for a lumbar puncture for a (CSF) analysis to confirm the diagnosis of Guillain-Barré syndrome.
3. Which intervention will the nurse implement prior to this procedure? A) Keep Amid NPO. INCORRECT Amid does not need to be NPO prior to this procedure. B) Instruct Amid not to void. INCORRECT Amid should void prior to this procedure to help prevent accidental puncture of the bladder during procedure. C) Obtain informed consent. CORRECT Amid is alert and oriented and has not received any pain medication, therefore, he is capable of g the consent form allowing this invasive procedure.
D) Place a saline lock in the hand. INCORRECT A lumbar puncture does not require a saline lock insertion for the procedure. Points Earned:
1.0/1.0
Correct Answer(s): C
The healthcare provider performs the lumbar puncture at Amid's bedside.
4. Which intervention should the nurse implement postprocedure? A) Keep Amid in a side-lying position. INCORRECT Amid should lie prone or supine for 3-4 hours after the procedure to help reduce leakage of the CSF. B) Apply pressure to the puncture site. INCORRECT A band-aid is placed over the puncture site and pressure does not need to be applied to the site. C) Assess Amid's brachial pulses. INCORRECT The nurse should complete a neuromuscular assessment of the lower extremities rather than the upper extremities. D) Increase Amid's fluid intake. CORRECT Increased fluid intake helps prevent a post-procedure headache which may occur after a lumbar puncture. The healthcare provider confirms the diagnosis of Guillain-Barré syndrome and discusses this with Amid but his family is not in the room. Points Earned:
1.0/1.0
Correct Answer(s): D
Cultural/Spiritual Needs
The nurse obtains additional assessment data and plans care related to Amid's cultural needs.
5. Which action indicates the nurse understands Muslim food and beverage preferences?
A) Allow Amid to have one glass of red wine to relax in the evening. INCORRECT Muslims do not believe in drinking alcohol. B) Instruct Amid's family that they will need to meet Amid's dietary needs. INCORRECT The family can bring specific dishes/foods, but the hospital must provide Amid with meals that acknowledge his cultural dietary restrictions. The family is not responsible for providing Amid's nutritional needs. C) Notify the dietary department that Amid cannot eat any pork. CORRECT The Muslim faith prohibits eating any type of pork. D) Help Amid select menu items that do not contain any dairy products. INCORRECT The Muslim faith has food/beverage preferences that the nurse should respect, but avoiding dairy products is not one of the restrictions in the Muslim faith. Points Earned:
1.0/1.0
Correct Answer(s): C
The nurse asks Amid, "How can the healthcare team best your Muslim faith while you are in the hospital?"
6. Which statement by Amid reflects the Muslim faith? A) "I must be able to pray five times a day." CORRECT The Muslim faith teaches its followers to pray five times a day facing toward Mecca. B) "If I die, please face me toward the sun." INCORRECT After death, a Muslim's face must be toward Mecca (northeast) rather than toward the sun. C) "My wife must cleanse my body if I should die." INCORRECT After death, the clothes must be removed and the body cleansed by a person of the same gender. D) "I must fast tomorrow because it will be Friday." INCORRECT Friday is the holy day for the Muslim faith, but fasting is not part of the Muslim faith. Points Earned:
0.0/1.0
Correct Answer(s): A
Legal Issues
The nurse is transcribing the healthcare provider's itting prescriptions. The nurse is having difficulty reading one of the prescriptions.
7. Which action should the nurse implement? A) Implement the prescription as fully as possible based on its legibility. INCORRECT This action increases the risk for a medication error. B) the director of nurses to help understand the prescription. INCORRECT It is not the responsibility of the director of nurses to interpret illegible prescriptions. C) the prescription during the healthcare provider's routine rounds. INCORRECT This delays the implementation of the prescriptions. D) Notify the healthcare provider immediately to clarify the prescription. CORRECT If the nurse is unable to clearly read and understand the healthcare provider's prescription, it must be clarified immediately with the person who wrote the prescription. Points Earned:
1.0/1.0
Correct Answer(s): D
Later during the shift, the nurse enters Amid's room and meets Amid's brother and his wife, who is in traditional Muslim dress with her face covered. Amid's brother states, "Amid tells me he has a syndrome but can't explain to me what is going on, can you tell me what is wrong with my brother?"
8. How should the nurse respond? A) "According to the privacy law, I cannot discuss this information with you." INCORRECT This response is not a correct interpretation of HIPPA regulations. B) "I will Mr. Haq's healthcare provider so that he can explain it to you." INCORRECT
The nurse can discuss Guillain-Barré syndrome with the client and his family. C) "I can discuss Amid's condition with his wife but not with you in the room." INCORRECT The nurse does not understand the HIPPA rules and regulations when making this statement. D) "He has muscle weakness that is traveling up his body and may get worse." CORRECT Amid's presence in the room can be understood by the nurse as implied consent. Therefore, the nurse can answer the brother's questions and give factual information that is understood by laypersons. Points Earned:
1.0/1.0
Correct Answer(s): D
Nursing Diagnosis
The nurse on the medical floor is developing a plan of care for Amid, based on the expected clinical pathway of the syndrome.
9. Which nursing diagnosis will take priority for Amid as the syndrome progresses? A) High risk for injury related to inability to ambulate and transfer safely. INCORRECT Safety is an important issue for Amid, but this is not the highest priority nursing diagnosis. B) Fear and anxiety related to hospitalization and loss of control. INCORRECT Amid's psychological needs are important, but psychosocial problems are of less priority than another diagnosis. C) Altered nutrition, less than body requirements, related to inability to swallow. INCORRECT Amid has had choking episodes and is at risk for inability to swallow due to the disease process, but this is not the highest priority nursing diagnosis. D) Ineffective breathing pattern related to progressive muscle weakness. CORRECT Guillain-Barré syndrome causes ascending paralysis that will cause respiratory failure. Therefore, the diagnosis of ineffective breathing pattern will take priority during the course of the syndrome. Maslow's Hierarchy of Needs. Points Earned:
1.0/1.0
Correct Answer(s): D
The nurse includes the nursing diagnosis, "Impaired physical mobility related to paralysis" in the plan of care.
10. Which long term goal is written for this nursing diagnosis? A) The client will have no skin breakdown or irritation. INCORRECT This is indicated for the nursing diagnosis, "risk for impaired skin breakdown." B) The client will have minimal muscle atrophy. CORRECT A client with Guillain-Barré syndrome will not be able to move the extremities during the course of the syndrome. Therefore, preventing muscle atrophy is an appropriate long term goal. C) The client will perform active range of motion exercises. INCORRECT The client will not be able to move the extremities. Therefore, the nurse will have to perform ive range of motion exercises. D) The client will be turned every 2 hours while awake. INCORRECT This is a nursing intervention rather than a goal. Additionally, the client should also be turned while he is sleeping, unless he is on a special immobility bed. Points Earned:
1.0/1.0
Correct Answer(s): B
Ventilator Care
Two days after ission, Amid starts complaining of difficulty breathing. His numbness is ascending up his body and affecting his respiratory muscles. He is transferred to the Intensive Care Department and placed on a ventilator for respiratory . Assessment of the patient is the most important aspect of nursing care during the acute phase. The nurse must monitor the ascending paralysis; assess respiratory function; monitor arterial blood gases (ABGs); and assess the gag, corneal, and swallowing reflexes during the routine assessment. Reflexes are usually decreased or absent.
11. Which intervention will the Intensive Care Department nurse implement first? A) Confirm that the ventilator settings are correct. INCORRECT Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is important, but this is not the first intervention the nurse should implement.
B) that ventilator alarms are functioning properly. INCORRECT Making sure alarms are functioning properly is important, but another action is of higher priority. C) Assess the respiratory status and pulse oximeter reading. CORRECT Assessment is the first step of the nursing process and is the first action the nurse should implement when caring for a client on a ventilator. D) Monitor Amid's arterial blood gas results. INCORRECT Monitoring lab results is an important intervention for the client on a ventilator, but is not the priority intervention. Points Earned:
1.0/1.0
Correct Answer(s): C
12. Which intervention addressing the mechanical ventilator should be included in the nursing care plan? A) Alternate the position of the endotracheal (ET) tube in the mouth daily. CORRECT Alternating the ET tube will help prevent the development of a pressure ulcer on the client's tongue. B) Obtain a chest x-ray daily to determine correct position of the ET tube. INCORRECT A CXR is done immediately after insertion of the ET tube, but the nurse must check the lip line daily to determine position of the ET tube rather than obtaining a daily CXR. C) Check daily to ensure that the client's endotracheal cuff is deflated. INCORRECT The cuff should be inflated with no more than 25 cm H2O to ensure there is no air leakage, and must be checked every 4 to 8 hours, not daily. D) Ensure that 3 fingers can be inserted under the ties securing the ET tube. INCORRECT The ties should be snug but not too tight, usually inserting one finger under the tie is sufficient. Points Earned:
0.0/1.0
Correct Answer(s): A
Communication Skills
After Amid is settled and resting comfortably in the Intensive Care Department, the nurse escorts Amid's wife and brother into his room. Amid's eyes are open and he is aware of what is going on around him. Amid's wife starts crying uncontrollably which causes Amid to start fighting the ventilator and crying as well.
13. Which action should the nurse implement? A) Tell the wife she must stop crying or she will not be able to visit again. INCORRECT This action does not address the fears of Amid's wife. Additionally, preventing her from visiting will not meet Amid's or his wife's psychosocial needs. B) Escort Amid's wife out of the room and back to the waiting area. INCORRECT This action does not address the fears of Amid's wife. C) Medicate Amid immediately so that he will quit fighting the ventilator. INCORRECT This action does not address the fears of Amid's wife. D) Acknowledge the wife's fears and explain about the ventilator and machines. CORRECT This is a frightening situation and environment, so the nurse should acknowledge the wife's fears, and spend time explaining all the machines as well as the intensive care environment. Seeing that his wife's fears are respected and that she is cared for is likely to be the most effective measure to reduce Amid's anxiety and help him relax. Points Earned:
1.0/1.0
Correct Answer(s): D
After Amid quits fighting the ventilator, Amid's brother asks the nurse, "How will you communicate with my brother?"
14. Which statement is the nurse's best response?
A) "He will write what he needs on an erase slate board kept at the bedside." INCORRECT The ascending paralysis has reached his respiratory muscles. Therefore, Amid will not be able to use his hands to write. B) "I will ask yes/no questions and he can blink once for no and twice for yes." CORRECT Amid will not be able to use his arms due to the paralysis but he can blink his eyes.
C) "A speech therapist will help us communicate with your brother." INCORRECT A speech therapist will not be able to help Amid communicate while he is on the ventilator. D) "We will make sure the call light is available if he needs to call us." INCORRECT The ascending paralysis has reached his respiratory muscles. Therefore, Amid will not be able to use his hands to push the call light. Points Earned:
1.0/1.0
Correct Answer(s): B
A communication system must be established with the use of the patient's available abilities. This is extremely difficult if the disease progresses to involvement of the critical nerves. At the peak of a severe episode the patient may be incapable of communicating. The nurse must explain all procedures before doing them and reassure the patient that muscle function will return.
A Complication Occurs
During the night shift, Amid starts having difficulty breathing. The nurse checks the ventilator and realizes something is wrong but is unable to fix the problem. Amid is in obvious acute respiratory distress.
15. Which intervention should the nurse implement first? A) Notify the respiratory therapist immediately. INCORRECT The nurse must first address Amid's acute respiratory distress and then notification of other departments can be done. B) Ventilate with a manual resuscitation bag. CORRECT If the ventilator system malfunctions the nurse must ventilate the client with a manual resuscitation bag until the problem is resolved. C) Request stat arterial blood gases. INCORRECT The nurse must first address Amid's respiratory distress before requesting any laboratory data. D) Auscultate the client's lung sounds. INCORRECT
In some instances, assessment is not the priority. In this situation, the client is in "obvious acute respiratory distress," therefore the nurse should intervene without further assessment to help the client breathe. Points Earned:
1.0/1.0
Correct Answer(s): B
The respiratory therapist fixes the ventilator and Amid is placed back on the ventilator. The healthcare provider requests stat arterial blood gases (ABG). The ABG results are: pH 7.38, PaO 2 92, PaCO2 38, HCO3 24.
16. Based on evaluation of the ABG results, which action will the nurse implement? A) Continue to monitor Amid without taking any action. CORRECT These arterial blood gases are within normal limits, which means the manual resuscitation was performed correctly and no further action is required. B) Increase the FIO2 rate to 100% oxygen for 10 minutes. INCORRECT The client's oxygen rate does not need to be increased based on these ABG results. C) Suction the client immediately via the end line suction. INCORRECT These ABG results do not indicate that the client needs to be suctioned. D) Encourage the client to take slow deep breaths. INCORRECT The client is on a ventilator and is unable to independently take slow deep breaths. Points Earned:
0.0/1.0
Correct Answer(s): A
Two hours after Amid is placed back on the ventilator the machine alarm goes off and there is an increase in the peak airway pressure.
17. Which intervention will the nurse implement first? A) Check the tubing for any kinks. CORRECT When peak airway pressure is increased the nurse should implement the intervention that is least invasive for the client. This alarm may sound as the result of a plugged airway, "bucking" the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.
B) Suction the client's airway for secretions. INCORRECT The alarm may indicate the client needs suctioning but the nurse should always begin with the least invasive procedure when troubleshooting a ventilator alarm. C) Manually ventilate the client. INCORRECT This action may be needed, but it is not the first intervention. The client should not be removed from the ventilator unless no other option is available. D) Sedate the client with a muscle relaxant. INCORRECT This action may be needed, but the nurse should not sedate the client unless absolute necessary. Points Earned:
1.0/1.0
Correct Answer(s): A
Tracheostomy Placement
Ten days later Amid is still receiving mechanical ventilation via the endotracheal tube. The healthcare provider has determined that Amid will need a tracheostomy since it is not known how much longer he will require ventilator . Amid's brother asks, "Why does he need to have this procedure? Is he getting worse?"
18. How should the nurse respond? A) "We are not sure if your brother is getting worse, but he needs a trach." INCORRECT This is a vague answer. In addition, the tracheostomy is not planned because the client is getting worse. B) "Your brother will be able to talk with you after having this procedure." INCORRECT A tracheostomy byes the upper airway. Therefore, the client will not be able to talk. C) "If the tube stays in his mouth too long it may injure his vocal cords." CORRECT The endotracheal tube (ET) is placed through the vocal cords into the trachea and can cause damage if left in place too long; a client usually has an ET tube for 10 to 14 days. D) "The tracheostomy procedure will allow Amid to breathe more on his own." INCORRECT The ventilator will be connected to a tracheostomy tube instead of the endotracheal tube. There will be no difference in ability to breathe independently.
Points Earned:
1.0/1.0
Correct Answer(s): C
19. Which intervention will the nurse implement when providing tracheostomy care for Amid? A) Ensure that the low pressure tracheostomy cuff is deflated. INCORRECT The tracheostomy cuff must be inflated to prevent air leaks and tracheal aspiration while the client is on the ventilator. B) Remove the soiled twill tape before replacing the new twill tape. INCORRECT The nurse should place the new tape in place before removing the soiled tape to prevent the tracheostomy tube from being dislodged. C) Position the ventilator tubing to ensure minimal pulling on the tube. CORRECT This will reduce the risk of trauma to the trachea. D) Perform tracheostomy care daily, including removal of the inner cannula. INCORRECT Tracheostomy care should be performed at least every 8 hours to prevent infection. The inner cannula should not be removed because the client will have to be off the ventilator during the cleaning. Points Earned:
0.0/1.0
Correct Answer(s): C
The nurse is aware that Amid is at risk for complications secondary to being on the ventilator. The nurse performs frequent assessments of Amid.
20. Which assessment data would indicate the client is experiencing a complication secondary to the ventilator? A) The client's urine output is 100 ml in 2 hours. INCORRECT A urine output of 30 ml/hr indicates the kidneys are functioning properly. B) The pulse oximeter reading is greater than 95%. INCORRECT This indicates that the client is being adequately oxygenated. C) The client has asymmetrical chest expansion. CORRECT
Asymmetrical chest expansion indicates the client has had a pneumothroax which is a complication of ventilation. D) The telemetry shows occasional premature ventricular contractions. INCORRECT Occasional premature ventricular contractions occur in most clients and do not indicate a complication secondary to the ventilator. Fortunately, Amid does not experience any complications from the ventilator. Two weeks later, Amid's paralysis suddenly stops and starts descending as expected with Guillain-Barré syndrome. Amid is successfully weaned from the ventilator since his respiratory muscles are no longer paralyzed. Points Earned:
1.0/1.0
Correct Answer(s): C
Management Considerations
Amid is transferred to the medical floor. The unlicensed nursing personnel (UAP) is bathing the client with the bed in a high position with the opposite side rail raised.
21. Which action will the nurse implement? A) Demonstrate the correct technique when giving a bed bath. INCORRECT There is no need for the nurse to demonstrate this skill. B) Encourage the UAP to put the bed in the lowest position. INCORRECT The bed should be at a comfortable height for the UAP to bathe the client for best body mechanics. C) Instruct the UAP to get another person to help with the bath. INCORRECT The UAP can bathe a client without assistance, if the client's safety can be ensured. D) Provide praise for performing the bath safely for Amid and the UAP. CORRECT Raising the opposite side rail addresses Amid's safety to ensure that he will not fall out of bed while being turned. Having the bed in the high position is demonstrating proper body techniques by the UAP. Points Earned:
1.0/1.0
Correct Answer(s): D
The UAP and the nurse are caring for five clients including Amid for the 12-hour shift.
22. Which nursing task can the nurse safely delegate to the unlicensed assistive personnel (UAP)? A) Escort a client in a wheel chair to the hospital patio area. CORRECT The UAP may escort a client outside as long as the client is stable. B) Determine a client's ability to do range of motion exercises. INCORRECT Assessment cannot be delegated to a UAP. C) Help feed a client who has had multiple choking episodes. INCORRECT The nurse cannot delegate tasks for clients with unstable conditions, such as choking. D) Teach a client how to apply a gait belt before ambulating. INCORRECT The nurse cannot delegate teaching to a UAP. Points Earned:
1.0/1.0
Correct Answer(s): A
Rehabilitation Care
The nurse assesses Amid and performs bedtime care. Amid's wife asks the nurse, "How long before my husband is back to normal? I miss him so much."
23. The nurse's response will be based on which scientific rationale? A) Full recovery usually occurs within several months to a year after onset of symptoms. CORRECT This is the correct scientific rationale when answering the wife's question. B) Most clients with Guillain-Barré syndrome have some type of residual disability. INCORRECT Guillain-Barré syndrome results in permanent residual disability in about 10% of cases. C) The majority of clients with this syndrome end up on mechanical ventilation for life. INCORRECT This response indicates that the nurse does not understand the typical course for a client diagnosed with Guillain-Barré syndrome.
D) The rehabilitation phase is short and the client is fully recovered within a month. INCORRECT This response indicates that the nurse does not understand the typical course for a client diagnosed with Guillain-Barré syndrome. Points Earned:
1.0/1.0
Correct Answer(s): A
Throughout the course of the illness, the nurse needs to provide and encouragement to the family and patient. Because residual problems and relapses are uncommon except in the chronic form of the disease, complete recovery can be anticipated although it is generally a slow process that takes months or years if axonal degeneration occurs. Amid continues to improve, is able to breathe without use of the ventilator, and is transferred to the rehabilitation unit with plans to be discharged to his brother's home within the next month.
24. Which referral is most important for the rehabilitation nurse case manager to implement initially upon his transfer to the rehab unit? A) Guillain-Barré Syndrome Foundation. INCORRECT This referral will be helpful to provide and additional information, but is not the most important referral upon arrival in the rehab unit. B) Physical therapist. CORRECT The physical therapist will help with gait training, muscle building, and transfer techniques. It is essential that this training be started as soon as the client is transferred to the rehab unit to promote early discharge and reduce the risk of injury. C) Hospital dietician. INCORRECT The client may benefit from dietary counseling to help build his strength. However, another referral is of higher priority. D) Home health care services. INCORRECT Early discharge planning will be beneficial; however, rehab typically will require at least a month, so another referral is of greater immediacy. Points Earned:
0.0/1.0
Correct Answer(s): B
Discharge
Amid works hard during rehabilitation and is able to ambulate with a walker or a cane. He gets tired easily and has regained some of his strength, but needs some assistance when getting out of the bed and chair. He has been in the rehabilitation unit for 1 month and is scheduled to be discharged to his brother's home in 2 days.
25. Which intervention should the nurse implement prior to Amid's discharge from the rehabilitation unit? A) Make a referral to the social worker to evaluate the home for safety. INCORRECT The occupational therapist will evaluate Amid's brother's home for safety, the social worker addresses financial or discharge concerns. B) Show Amid how to perform ive range of motion exercises. INCORRECT Amid must perform active range of motion exercises to regain his strength. No one should do them for him (ive). C) Arrange to have a Hoyer lift sent to Amid's brother's home. INCORRECT A Hoyer lift is used to transfer an immobile client from a bed to chair. Amid can transfer himself with assistance. D) Demonstrate proper body mechanics to Amid's wife and brother. CORRECT Since Amid is having difficulty getting out of the bed and chair his family should be taught correct techniques to help transfer Amid. This will help prevent injury to both Amid and his family . Points Earned:
0.0/1.0
Correct Answer(s): D
The day for Amid's discharge has finally arrived. The nurse escorts Amid, along with his wife and brother, to the car. Amid asks the nurse, "May I visit the mosque on my way home?"
26. What is the best response by the nurse? A) "I would recommend going straight home. You will be very tired." INCORRECT This response does not Amid's cultural needs.
B) "A visit to the mosque would be just fine; I know your faith is important." CORRECT Amid's Muslim faith is very strong, and visiting the mosque is important to him. He has not been able to visit in over 2 months and the nurse should his spiritual and cultural needs. C) "Your wife should probably decide if you should visit the mosque." INCORRECT Decision-making in the Muslim faith is typically the responsibility of the man. The nurse should allow the couple to adhere to their own style of decision-making, and respect their traditions, rather than offering the advice that the wife should make this decision. D) "Do you think you are strong enough to make a visit to the mosque?" INCORRECT If Amid is being discharged from the rehabilitation unit, he should be strong enough to visit the mosque and practice his faith. Points Earned:
1.0/1.0
Correct Answer(s): B
Case Outcome
Amid visits the mosque on the way home. He plans to stay with his brother for 2 more months then return to his home. He was referred to a home healthcare agency and will be receiving weekly visits from the home healthcare nurse and physical therapist. The rehabilitation team expects Amid to make a full recovery within the next year. The expected outcomes are that the patient with Guillain-Barré syndrome will:
return to usual level of physical functioning be free from pain and discomfort maintain nutritional status
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