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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice B rationale:
The semi-Fowler's position involves elevating the head of the bed to 30-45 degrees, which is useful for clients with respiratory issues to promote lung expansion. However, for auscultation of the posterior lung fields in a client with left lower lobe pneumonia, the lateral, semi-prone position is more appropriate as it allows better access to the specific area of concern.
Choice C rationale:
Placing the client on the right side-lying position may not be as effective for auscultating the left lower lobe, as the target area is located on the opposite side. The lateral, semi-prone position offers better access to the left lower lobe for assessment.
Choice D rationale:
The forward orthopneic position is a sitting position with the arms supported on a table or over the bed. While this position can assist clients with breathing difficulties, it is not suitable for auscultation of the posterior lung fields. The lateral, semi-prone position is moreappropriate for this purpose.
Correct Answer is D
Explanation
The correct answer is choice D. Don non-sterile gloves when performing direct care.
Choice A rationale:
Placing a surgical mask on the client during transport is not necessary for preventing the spread of Clostridium difficile. C. difficile is primarily spread through contact with contaminated surfaces and not through airborne transmission.
Choice B rationale:
Keeping the door closed to the client’s room at all times is not required for C. difficile infection. The focus should be on contact precautions rather than airborne precautions.
Choice C rationale:
Wearing a particulate respirator mask is not needed for C. difficile, as it is not an airborne pathogen. Standard contact precautions are sufficient.
Choice D rationale:
Donning non-sterile gloves when performing direct care is essential to prevent the spread of C. difficile. The spores can be transmitted via the hands of healthcare workers, so wearing gloves helps to minimize this risk.
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