A nurse is assigned to care for a client on a medical-surgical unit.

Exhibits

Complete the following sentence by using the list of options.
Based on the information provided, the client is likely experiencing

which is caused by

A. Guillain-Barre Syndrome is not a contagious disease. It is an autoimmune disorder that occurs when the immune system mistakenly attacks the peripheral nerves. GBS is not spread through respiratory droplets or any other form of infection transmission.
B. Guillain-Barre Syndrome causes demyelination in the peripheral nervous system, not the central nervous system. The central nervous system includes the brain and spinal cord, whereas the peripheral nervous system comprises the nerves outside the brain and spinal cord.
C. Guillain-Barre Syndrome is not a genetic disorder. It is considered an autoimmune condition that can be triggered by an infection or other environmental factors. While there may be genetic predispositions that affect susceptibility to autoimmune conditions, GBS itself is not classified as a genetic disorder.
D. Guillain-Barre Syndrome primarily affects the peripheral nervous system. It involves an immune- mediated attack on the peripheral nerves, leading to symptoms such as muscle weakness, tingling, and loss of reflexes.

A. This blood pressure and heart rate are within normal ranges for most patients. For example, a blood pressure of 132/60 mmHg is slightly elevated on the systolic side but not critically so, and a heart rate of 90 beats per minute is within the normal range (60-100 beats per minute).
B. Continuous bladder irrigation is used to prevent clots and debris from obstructing the urinary tract after a TURP. If the output from the Foley catheter has stopped, it may indicate a blockage or clot in the catheter or bladder, which can lead to bladder distension, discomfort, and potential kidney damage.
Immediate reporting to the provider is crucial because this could indicate a severe complication.
C. Pain levels are subjective, and a pain level of 5/10 indicates moderate discomfort. While pain management is important, a pain level of 5/10 is not unusual after TURP, and it can often be managed with appropriate pain relief measures.
D. Pink-colored urine is not uncommon immediately following a TURP as a result of bleeding or irritation from the procedure. This finding can be expected and may not indicate an immediate complication.
However, if the urine color changes to bright red or if there is a significant increase in blood, it could be more concerning.