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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- While missed meals can contribute to glucose fluctuations, the abrupt onset of diabetic ketoacidosis (DKA) suggests a more immediate cause, such as insulin-related factors.
B) Correct- Diabetic ketoacidosis (DKA) occurs due to a lack of sufficient insulin, resulting in the body breaking down fat for energy and producing ketones. While all the options can contribute to DKA, the most likely cause in this scenario is administering too much insulin. This can lead to a rapid drop in blood glucose levels, causing the body to initiate ketone production for energy.
C) Incorrect- While infections can contribute to insulin resistance, they are not the most common cause of the rapid development of diabetic ketoacidosis (DKA) seen in this scenario.
D) Incorrect- Eating extra food would likely lead to higher glucose levels but wouldn't cause the rapid and severe ketone production characteristic of diabetic ketoacidosis (DKA).
Correct Answer is A
Explanation
This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.
The other options are not correct because:
B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.
C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.
D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.
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