The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)

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.

When a client expresses fear and uncertainty about undergoing surgery, it is important for the practical nurse (PN) to communicate this information to the charge nurse or the healthcare provider. By notifying the appropriate person, the PN ensures that the client's concerns are addressed and appropriate interventions can be implemented.

Options a) and c) are not the priority actions because documenting the client's concerns or reminding them about the signed consent does not address their emotional needs or provide support.

Option b) may not be the most appropriate response, as simply encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainties may not be sufficient to alleviate their anxiety.

Therefore, the best course of action is to notify the charge nurse or healthcare provider so that they can assess the client's concerns, provide reassurance, and address any questions or fears the client may have prior to the surgery.