While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?

The correct answer is Choice D.

Choice A rationale: Enrolling the UAP in a hospital education class on conducting safe client care is not an immediate response and does not address the current situation. It may be a longer-term solution for ongoing education.

Choice B rationale: Praising the UAP for performing oral hygiene and encouraging family participation does not address the immediate safety concern of the procedure being performed correctly.

Choice C rationale: Telling the UAP to continue because the unconscious client is positioned safely is incorrect. The client should not be in a flat side-lying position as it increases the risk of aspiration during oral hygiene.

Choice D rationale: Stopping the procedure and telling the UAP to place the client in a Fowler's position is correct. The Fowler's position helps maintain an open airway and reduces the risk of aspiration during oral hygiene in an unconscious client.

The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.

Choice A rationale:

The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.

Choice B rationale:

Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.

Choice C rationale:

Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.

Choice D rationale:

Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.