While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Profuse sweating.

Weakness in the lower legs.

Loss of sensation at T-8.

Leg pain that worsens at night.

Answer and Explanation

The Correct Answer is C

Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.

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Correct Answer is A

Explanation

Choice A rationale
Encouraging the client to continue their walking routine is a supportive and positive response. This acknowledges the client’s desire to stay active and engage in activities they enjoy despite their osteoarthritis. It promotes a sense of empowerment and independence, which can be important for overall well-being.
Choice B rationale
Advising less weight-bearing to prevent joint destruction may seem logical, but it is not the best advice. Regular exercise, including walking, can actually help manage osteoarthritis by strengthening the muscles around the joints, improving flexibility, and reducing pain.
Choice C rationale
Recommending walking indoors for improved stability and safety might be helpful in some cases, but it is not necessarily the best response. The client has expressed a desire to continue walking in the park with friends, which also has social and mental health benefits.
Choice D rationale
Suggesting a calcium supplement along with continued walking is not the best advice. While calcium is important for bone health, osteoarthritis is not caused by a lack of calcium. It’s a degenerative joint disease that involves the breakdown of cartilage in the joints.

A. Maintain elevated positioning of the dependent joints on the affected side. B. Verify prescribed laboratory tests include prothrombin time and platelet count. C. Start two large-bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. D. Administer aspirin to prevent further clot formation and platelet clumping.

Correct Answer is C

Explanation

Choice A rationale
While maintaining elevated positioning of the dependent joints on the affected side can be helpful in certain conditions such as edema or injury, it is not the immediate intervention needed for a client presenting with sudden, severe facial numbness, uneven smile with facial droop to the right side, and a hand grasp strength that is weaker on the right than the left.
Choice B rationale
Verifying prescribed laboratory tests including prothrombin time and platelet count is important in assessing the client’s coagulation status. However, it is not the immediate intervention needed in this situation.
Choice C rationale
The client’s symptoms are suggestive of a stroke. In such cases, immediate medical intervention is crucial. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is an appropriate immediate intervention.
Choice D rationale
Administering aspirin can be beneficial in preventing further clot formation and platelet clumping in clients at risk of a stroke. However, it is not the immediate intervention needed in this situation.

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While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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