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 C
Explanation
Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.
Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.
Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.
Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.
Correct Answer is D
Explanation
Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.
Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.
Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.
Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.
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