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: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.
Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.
Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.
Choice D Rationale: Documenting the incident is important but should follow
Correct Answer is D
Explanation
Choice A Rationale: Eating only cold foods is not a common recommendation for preventing trigeminal neuralgia flare-ups.
Choice B Rationale: Massaging the affected side multiple times a day is not typically recommended and may exacerbate symptoms.
Choice C Rationale: Applying heat or cold to alleviate symptoms can vary depending on individual preferences and is not a primary preventive measure for triggering an acute onset.
Choice D Rationale: Using a soft bristle toothbrush and warmed mouthwash is a recommended preventive measure to avoid triggering acute episodes of trigeminal neuralgia. It helps reduce irritation to the affected nerves.
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