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. Apply a pain scale to describe intensity.

Choice A rationale:

Asking about elements of the pain experience is important for a comprehensive pain assessment, but it is not the most critical aspect immediately after administering an analgesic. This step is more relevant during the initial assessment to understand the nature and characteristics of the pain.

Choice B rationale:

Questioning the client about precipitating factors can help identify what triggers the pain, which is useful for long-term pain management strategies. However, this is not the primary focus after giving an analgesic, as the immediate goal is to evaluate the effectiveness of the pain relief.

Choice C rationale:

Locating where in the body the pain occurs is essential for diagnosing and understanding the pain’s origin. However, after administering an analgesic, the priority is to assess the change in pain intensity rather than its location.

Choice D rationale:

Applying a pain scale to describe intensity is crucial after giving an analgesic because it provides a quantifiable measure of the pain relief achieved. This helps in determining the effectiveness of the medication and guides further pain management interventions.

By focusing on the pain intensity using a standardized pain scale, the practical nurse can objectively evaluate the patient’s response to the analgesic and make informed decisions about any additional pain management needs.

The correct answer is choice B. Ineffective airway clearance.

Choice A rationale:

Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.