When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician?
A A report by the client of difficulty sleeping
B Removing the sequential compression device once a shift
C Hypoactive bowel sounds
D Glasgow Coma Score of 15
The Correct Answer is C
Choice A Rationale: Reporting difficulty sleeping may be important but is not typically a critical concern in Guillain-Barre Syndrome.
Choice B Rationale: Removing the sequential compression device once a shift may require clarification or education but is not a significant medical concern.
Choice C Rationale: Hypoactive bowel sounds can indicate a potential bowel obstruction or paralytic ileus, which is a significant medical concern in clients with Guillain-Barre Syndrome and should be reported to the physician.
Choice D Rationale: A Glasgow Coma Score of 15 is within the normal range and would not typically require reporting to the physician in the context of Guillain-Barre Syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Loosening all of the connections on the vest to assess the skin is not the first priority and may compromise the stability of the halo brace.
Choice B Rationale: Asking about the client's ability to perform range of motion to legs is important but may not be the first priority.
Choice C Rationale: Asking how the client is able to reposition self in bed is important but may not be the first priority.
Choice D Rationale: Assessing the pin sites is the first priority in caring for a client with a halo brace, as complications related to pin site infections or issues can have significant consequences. Pin site care and assessment are crucial to prevent infections and complications.
Correct Answer is A
Explanation
Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.
Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.
Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.
Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.
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