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

Irregular heart rate.

Profuse diaphoresis.

Lower leg weakness.

Full facial ﬂushing.

Answer and Explanation

The Correct Answer is A

This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can aﬀect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.

B. Profuse diaphoresis is not a priority finding and may be related to other factors such as fever, anxiety, or medication side eﬀects.

C. Lower leg weakness is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or aﬀects the respiratory muscles.

D. Full facial ﬂushing is not a priority finding and may be related to other factors such as vasodilation, inﬂammation, or medication side eﬀects.

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Correct Answer is B

Explanation

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's attention to another topic or activity and document the incident.

A. The size of my breasts is of no concern to you is not the best response because it may sound defensive or sarcastic and may not deter the adolescent from making similar comments in the future.

C. Do you really think so? is not the best response because it may encourage or reinforce the adolescent's inappropriate or sexual comments and may imply that the PN is interested or ﬂattered by them.

D. If you talk like that again, I will tell your parents is not the best response because it may sound threatening or punitive and may not address the underlying issue of the adolescent's behavior. The PN should inform the parents only if the behavior persists or escalates.

A. Clean up and organize the nurses' work-station. B. Verify completion of all new prescriptions. C. Calculate and record intake and output totals. D. Write a narrative shift summary for each client.

Correct Answer is B

Explanation

This is the highest priority task and should be completed first because it ensures the safety and quality of care for the clients. The PN should check that all new prescriptions have been administered, documented, and reported as ordered and that there are no errors or omissions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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