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. Use pyridostigmine as needed to relieve symptoms of muscle weakness and fatigue: Pyridostigmine should not be used on an "as-needed" basis, as it is a long-acting medication that works by maintaining a steady level of acetylcholine at the neuromuscular junction. The client needs to take the medication regularly at prescribed intervals, not sporadically, to maintain consistent symptom control. This statement reflects a misunderstanding of the medication's use.

B. Be able to crush the sustained release tablet because of difficulty swallowing: Sustained-release (or extended-release) tablets should not be crushed because doing so can cause the medication to be released too quickly, leading to potential side effects or overdose. If the client has difficulty swallowing, an alternative form of the medication, such as a liquid or split tablet, should be considered. This statement reflects a lack of understanding regarding the proper administration of the medication.

C. Skip a dose if I have symptoms of fatigue to minimize side effects of the medications: Skipping doses of pyridostigmine is not appropriate. The medication should be taken as prescribed, even if the client feels fatigued. Fatigue is a symptom of myasthenia gravis, not necessarily a side effect of the medication. Consistent dosing is important for controlling the disease and preventing worsening of symptoms. Skipping doses can lead to inadequate symptom control and potential exacerbation of weakness.

D. Take pyridostigmine 30-60 minutes before meals to improve muscle function: This statement indicates that the client understands the appropriate use of pyridostigmine for managing myasthenia gravis (MG). Pyridostigmine is an acetylcholinesterase inhibitor that helps improve neuromuscular transmission, and it is typically taken 30-60 minutes before meals. This timing helps optimize muscle strength during the period when the client is eating, as muscle weakness can make swallowing more difficult. By taking the medication before meals, the client is more likely to experience improved muscle function when needed most.

A. Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest B. Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing C. Decrease activity, increase bronchodilator use, and encourage pursed lip breathing D. Place in prone position, begin steroid therapy, and monitor glucose levels

Correct Answer is B

Explanation

A) Apply 4L of nasal oxygen, administer a cough suppressant, and place client on bedrest:
This approach is inappropriate for a client with bacterial pneumonia. While oxygen therapy may be necessary for some clients, administering a cough suppressant in this scenario is counterproductive. Pneumonia often leads to the accumulation of secretions, and suppressing the cough would prevent the client from clearing mucus from their airways, potentially worsening the condition. Bedrest is generally indicated, but it should not be the sole intervention.

B) Increase fluid intake, administer antibiotic(s), and facilitate adequate coughing:
This is the most appropriate plan of care. Increasing fluid intake helps to thin the mucus, making it easier to clear from the airways, which is crucial in pneumonia. Antibiotics are necessary to treat the bacterial infection causing pneumonia. Facilitating adequate coughing helps the client expel secretions, reducing the risk of airway obstruction and improving oxygenation. Coarse rhonchi indicate the presence of mucus or secretions, which should be cleared with effective coughing.

C) Decrease activity, increase bronchodilator use, and encourage pursed lip breathing:
Decreasing activity is generally appropriate for a client with pneumonia to reduce fatigue, but increasing bronchodilator use is not typically indicated unless there is underlying bronchospasm, such as in asthma or COPD. Pursed lip breathing can help improve ventilation, but it is more beneficial for clients with obstructive airway diseases, not primarily for those with bacterial pneumonia. Therefore, this option does not address the immediate needs of the client.

D) Place in prone position, begin steroid therapy, and monitor glucose levels:
While prone positioning is helpful in some conditions like acute respiratory distress syndrome (ARDS), it is not routinely used for bacterial pneumonia unless the client has severe hypoxemia and requires advanced respiratory support. Steroid therapy is generally not indicated for bacterial pneumonia unless there is a specific inflammatory component (such as a superimposed condition like asthma or COPD). Monitoring glucose levels may be important in clients on steroid therapy, but this is not a primary concern in the treatment of bacterial pneumonia.

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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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