At this time, based on the patient’s statement, the priority is Self-Care Deficit related to fatigue after physical therapy. Fatigue is described as an overwhelming feeling of lassitude or lack of physical or mental energy that interferes with activities.

Option A: The patient might be experiencing fatigue, but it might be due to the activities at physical therapy. Fatigue is one of the most common symptoms of MS, reported by at least 75% of patients with the disease.
Option B: Activity intolerance in a patient with MS is appropriate, but not related to the statement. An estimated 50–60% of persons with MS describe fatigue as one of their most bothersome symptoms, and it is a major reason for unemployment among MS patients.
Option C: Impaired physical mobility is appropriate to a patient with MS, but it is not related to the patient’s statement. Spasticity in MS is characterized by increased muscle tone and resistance to movement; it occurs most frequently in muscles that function to maintain an upright posture. The muscle stiffness greatly increases the energy expended to perform activities of daily living (ADLs), which in turn contributes to fatigue.

The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function. These patients are at risk for respiratory failure, which is urgent. Upon presentation, 40% of patients have a respiratory or oropharyngeal weakness. Ventilatory failure with required respiratory support occurs in up to one-third of patients at some time during the course of their disease.

Option A: These findings should be reported to the nurse but it is not an urgent matter. The typical patient with Guillain-Barré syndrome (GBS), which in most cases will manifest as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), presents 2-4 weeks following a relatively benign respiratory or gastrointestinal illness with complaints of finger dysesthesias and proximal muscle weakness of the lower extremities.
Option B: Facial weakness and difficulty of speaking are common signs of GBS and must be reported, but it is not a priority. The classic clinical picture of weakness is ascending and symmetrical in nature. The lower limbs are usually involved before the upper limbs. Proximal muscles may be involved earlier than the more distal ones. Trunk, bulbar, and respiratory muscles can be affected as well.
Option C: A rapid heart rate is important and should be reported to the nurse, but it is not life-threatening. Autonomic nervous system involvement with dysfunction in the sympathetic and parasympathetic systems can be observed in patients with GBS.

The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need intubation and mechanical ventilation.

Option A: The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen.
Option C: This patient’s vital signs need to be re-checked sooner than 1 hour.
Option D: Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization

Alteplase is a clot buster. With a patient who has experienced a hemorrhagic stroke, there is already bleeding into the brain. A drug like alteplase can worsen the bleeding.

Option A: This statement is correct, but it does not address the relevance of the drug to the patient’s diagnosis.
Option B: This is an accurate statement, but it does not clearly explain the effects of the drug on the patient.
Option D: This statement is also accurate about the use of alteplase, but it is not pertinent to this patient’s diagnosis.

Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions.

Option B: They often ignore the food on the left side of their food trays, so reminding them is a correct action.
Option C: Passive range of motion exercises help keep the left side of the patient’s body from atrophy as a result of unuse.
Option D: This is a correct action of the student nurse, as the patient may neglect the left side of the body.