A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Choice A Reason:

Increasing hydration is important in the postoperative period to maintain fluid balance and support recovery. However, it is not the immediate priority following pheochromocytoma removal. The primary concern is to monitor and manage hemodynamic stability, particularly blood pressure.

Choice B Reason:

Monitoring blood pressure is the priority action following pheochromocytoma removal. This surgery can lead to significant fluctuations in blood pressure due to the sudden removal of catecholamine-secreting tumors. Close monitoring is essential to detect and manage potential hypotension or hypertension, which can be life-threatening if not promptly addressed.

Choice C Reason:

Measuring urine output is important for assessing kidney function and fluid balance, but it is not the immediate priority. Blood pressure monitoring takes precedence because of the potential for severe hemodynamic instability following the removal of the tumor.

Choice D Reason:

Providing a calm environment is beneficial for the patient’s overall recovery and can help reduce stress and anxiety. However, it is not the most critical action immediately following surgery. Ensuring hemodynamic stability through blood pressure monitoring is the top priority.

Choice A Reason:

Using an electric shaver is recommended for clients who have received chemotherapy because it reduces the risk of cuts and bleeding. Chemotherapy can lower platelet counts, leading to an increased risk of bleeding. Traditional razors can cause nicks and cuts, which can be problematic for clients with low platelet counts.

Choice B Reason:

Avoiding crowds is crucial for clients who have received chemotherapy because their immune systems are often weakened, making them more susceptible to infections. Crowded places increase the risk of exposure to pathogens, which can lead to serious infections in immunocompromised individuals.

Choice C Reason:

Taking temperature weekly is not sufficient for clients who have received chemotherapy. These clients are at a higher risk of infections, and any sign of fever should be monitored closely. It is generally recommended to take the temperature daily or more frequently if the client feels unwell.

Choice D Reason:

Consuming a low-residue diet is not typically necessary for clients who have received chemotherapy unless they are experiencing specific gastrointestinal issues. A balanced diet with adequate nutrients is usually recommended to support overall health and recovery.

Choice E Reason:

Monitoring for bruising is important for clients who have received chemotherapy because it can indicate low platelet counts or other bleeding disorders. Early detection of bruising can help in managing and preventing more serious bleeding complications.