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 D
Explanation
Log-rolling is a technique of moving a client as a unit without twisting or bending the spine, which is used for clients with spinal injuries or surgeries. After log-rolling a client to a lateral position, the PN should place pillows to maintain alignment and prevent pressure ulcers or nerve damage. The pillows should be placed under the head, neck, upper arm, chest, abdomen, pelvis, and lower leg.
The other options are not correct because:
A. Raising the head of the bed 30 degrees is not necessary or appropriate after log-rolling a client to a lateral position, as it can cause shearing forces or compromise the spinal stability. The head of the bed should be kept flat or slightly elevated during log rolling.
B. Measuring blood pressure and pulse rate is not the immediate intervention after log-rolling a client to a lateral position, as it does not ensure the comfort or safety of the client. The PN should monitor the vital signs before and after log-rolling, but not during or immediately after.
C. Flexing legs and placing a blanket between legs is not the immediate intervention after log-rolling a client to a lateral position, as it does not support the spine or prevent pressure ulcers or nerve damage. The PN should keep the legs straight and aligned with the body during log-rolling, and place a pillow under the lower leg after log-rolling.
Correct Answer is C
Explanation
A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.
Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.
B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are
typically assessed to evaluate the circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.
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