A male client attends a community support program for mentally impaired and chemical-abusing clients. The client tells the practical nurse (PN) that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?

While caring for a client with Guillain-Barre syndrome, the practical nurse (PN) should report the finding of irregular heart rate to the charge nurse. Guillain-Barre syndrome is a neurological disorder that can affect multiple body systems, including the autonomic nervous system.

Autonomic dysfunction can lead to various cardiovascular abnormalities, such as changes in heart rate and rhythm.

However, irregular heart rate can indicate potential cardiac involvement or autonomic instability, which requires prompt evaluation and intervention. Therefore, the PN should report the finding of an irregular heart rate to the charge nurse for further assessment and appropriate management.

Incorrect:

A, B- Full facial flushing and profuse diaphoresis are common symptoms that can occur in Guillain-Barre syndrome due to autonomic dysfunction. While these findings should be noted and monitored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms.

C- Lower leg weakness is a characteristic symptom of Guillain-Barre syndrome and is expected in this condition. The PN should document and monitor the extent and progression of weakness but does not necessarily need to report it unless there are significant changes or complications.

- Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
- When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error

or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
- The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is a valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.

- Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.