The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

hyperglycemia

Urinary retention

Respiratory failure

Hypertension

Answer and Explanation

The Correct Answer is C

A. Hyperglycemia:
Although hyperglycemia can occur as a result of stress or corticosteroid use during the treatment of GBS (such as in the case of plasma exchange or IV immunoglobulin (IVIG) therapy), it is not the primary complication associated with GBS. While hyperglycemia requires monitoring and management, respiratory failure is a more immediate and critical concern.

B. Urinary retention:
Urinary retention can occur in some clients with neurologic disorders like GBS, but it is not as life-threatening as respiratory failure. The autonomic nervous system, which controls bladder function, may be affected, but urinary retention is usually manageable with intermittent catheterization or other interventions. It does not carry the same immediate risks to life or organ function as respiratory failure.

C. Respiratory failure:
In Guillain-Barré syndrome (GBS), the immune system attacks the peripheral nervous system, which can lead to progressive muscle weakness and paralysis. The most significant and potentially life-threatening complication of GBS is respiratory failure. This occurs because the paralysis can affect the muscles involved in breathing, including the diaphragm and intercostal muscles, leading to impaired ventilation. As the weakness progresses, the client may become unable to maintain effective breathing, requiring mechanical ventilation. Monitoring for signs of respiratory distress (e.g., increasing work of breathing, tachypnea, decreased breath sounds, or a drop in oxygen saturation) is critical in GBS, especially during the acute phase of the disease.

D. Hypertension:
Hypertension may be seen in some cases of GBS, particularly during the early stages of the disease, due to the autonomic dysfunction that can result from nerve involvement. However, hypotension (low blood pressure) is more commonly associated with the autonomic dysfunction in GBS rather than hypertension. Regardless, respiratory failure remains the most urgent complication to monitor for in clients with GBS.

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Correct Answer is D

Explanation

A) Fluid bolus and IV heparin:
A fluid bolus and IV heparin may be used in certain cardiovascular conditions, such as hypotension or in the setting of acute coronary syndrome (ACS) to prevent clot formation. However, in this case, the client is experiencing chest pain with ST segment elevations, a sign of ongoing ischemia, which suggests that the problem may be related to inadequate blood flow to the heart. Fluid boluses could exacerbate the condition if the heart's function is compromised, and IV heparin alone would not address the root cause of the ischemia. Hence, this is not the most appropriate intervention at this time.

B) A medical prescription for a stat chest x-ray:
A chest x-ray would not be immediately indicated in this scenario. The client's symptoms of chest pain, diaphoresis, and ST segment elevations on the ECG are indicative of myocardial ischemia or infarction, not a respiratory or structural lung issue that would be visualized on an x-ray. The priority here is to address the myocardial ischemia, which could be due to a clot or reocclusion in the coronary artery. A stat chest x-ray would not address the underlying cardiac issue, so this is not the best choice.

C) Coronary artery bypass (CABG) surgery if there is no improvement in 12 hours:
While CABG is an option for clients with severe coronary artery disease, it is generally considered when PCI is not successful or when there are multiple blockages that cannot be stented. In this situation, since the client has just undergone PCI and is now experiencing signs of reocclusion (e.g., chest pain, ST segment elevations), a repeat PCI with thrombectomy or angioplasty is more appropriate and urgent. Waiting 12 hours would delay treatment and risk further myocardial damage. CABG would not be the first intervention after a failed PCI within hours of the procedure.

D) Repeat PCI with thrombectomy or angioplasty:
This is the most appropriate intervention. The client's symptoms (chest pain, diaphoresis, and ST segment elevations) are suggestive of reocclusion of the stented artery, a complication that can occur after PCI. Reocclusion can cause further myocardial ischemia and infarction. A repeat PCI with thrombectomy or angioplasty would aim to reopen the blocked artery and restore blood flow to the myocardium, which is the immediate priority in this situation. This intervention can help resolve the ischemia and prevent further damage to the heart muscle.

A. dextromethorphan 10 mg PO q 4 r B. cromolyn MDI 2 puffs daily C. guaifenesin 200 mg PO q 4 hr D. methylprednisone 30 mg IV BID

Correct Answer is C

Explanation

A. Dextromethorphan 10 mg PO q 4 hr: Dextromethorphan is a cough suppressant, and while it may be useful for controlling a dry, non-productive cough, it is not appropriate for ineffective airway clearance in pneumonia. In fact, suppressing the cough in pneumonia could prevent the patient from clearing mucus from the airways, exacerbating the problem. It is more appropriate for a client who has a dry cough without significant mucus production.

B. Cromolyn MDI 2 puffs daily: Cromolyn is a mast cell stabilizer used for the prevention of asthma and allergy symptoms, and it is not typically used for treating pneumonia or ineffective airway clearance. It works by preventing the release of inflammatory mediators in response to allergens, but it does not address the issue of clearing mucus in the airways during a bacterial infection like pneumonia.

C. Guaifenesin 200 mg PO q 4 hr: Guaifenesin is an expectorant that helps loosen and thin mucus in the airways, making it easier for the client to cough up and clear secretions. This is the most appropriate medication for addressing ineffective airway clearance in a client with pneumonia, as the goal is to facilitate the removal of mucus and improve respiratory function. Guaifenesin does not suppress the cough reflex but instead promotes productive coughing, which is essential for clearing the airways during a respiratory infection like pneumonia.

D. Methylprednisolone 30 mg IV BID: Methylprednisolone is a corticosteroid used to reduce inflammation and control severe allergic or inflammatory conditions. While corticosteroids may be used in certain cases of pneumonia (e.g., in cases of significant inflammation or an underlying condition like COPD), they are not the first-line treatment for ineffective airway clearance. The priority in this case is to promote mucus clearance, which is better addressed by guaifenesin.

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The nurse is caring for the client experiencing Guillain-Barre syndrome (GBS). It is most important for the nurse to monitor the client for which complication?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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