A 24-year-old client is hospitalized with the Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is
determining level of consciousness.
checking strength of the extremities.
observing respiratory rate and effort.
monitoring the cardiac rhythm.
The Correct Answer is C
A. Determining level of consciousness: Guillain-Barré syndrome primarily affects the peripheral nervous system and motor function. Cognitive function is usually intact, so assessing level of consciousness is less critical for immediate life-threatening complications.
B. Checking strength of the extremities: Monitoring muscle strength is important for tracking disease progression, but it is not the most urgent assessment. Extremity weakness helps guide supportive care but does not immediately indicate life-threatening compromise.
C. Observing respiratory rate and effort: Respiratory muscle weakness can progress rapidly in Guillain-Barré syndrome, leading to respiratory failure. Close monitoring of respiratory rate, effort, and oxygenation is essential to detect early signs of ventilatory compromise and initiate mechanical ventilation if needed.
D. Monitoring the cardiac rhythm: Cardiac dysrhythmias can occur in Guillain-Barré syndrome due to autonomic dysfunction, but they are generally secondary concerns. The priority is maintaining adequate ventilation, as respiratory failure is the most immediate life-threatening risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood pressure 130/72, pulse 90, respirations 32: These values show mild changes from baseline and could reflect pain, anxiety, or mild physiological response. They are not immediately indicative of increased intracranial pressure.
B. Blood pressure 110/70, pulse 120, respirations 30: This pattern shows hypotension with compensatory tachycardia and mild tachypnea. While concerning, it may reflect hypovolemia rather than acute neurological deterioration.
C. Blood pressure 156/60, pulse 58, respirations 12: This represents Cushing’s triad—hypertension with widened pulse pressure, bradycardia, and irregular or slowed respirations—which is a classic sign of increased intracranial pressure and impending brain herniation. This is a neurological emergency requiring immediate intervention.
D. Blood pressure 148/78, pulse 112, respirations 28: These are elevated but less concerning than the pattern seen in option C. This may indicate pain, stress, or mild ICP increase but is not immediately life-threatening.
Correct Answer is C
Explanation
A. Assessing mucous membranes: Moisture and color of mucous membranes can provide some indication of hydration status, but this assessment is subjective and may not reflect rapid changes in intravascular volume during the emergent phase of burn care. It is supportive but not the most reliable measure of fluid adequacy.
B. Monitoring the blood pressure: Blood pressure can indicate overall circulatory status, but it may remain stable until significant fluid loss occurs. Relying solely on BP can delay recognition of inadequate perfusion, making it less sensitive for immediate fluid assessment in burn patients.
C. Measuring hourly urine output: Hourly urine output is the most accurate and direct indicator of kidney perfusion and fluid adequacy. Maintaining a target output (typically 0.5–1 mL/kg/hr in adults) confirms that the client is receiving sufficient fluids to support organ perfusion during the critical emergent phase of burn management.
D. Checking daily weight: Daily weight is useful for tracking overall fluid balance over time but is not practical for assessing real-time fluid adequacy in the emergent phase. Acute fluid shifts in burn patients require more immediate and continuous measures, such as hourly urine output.
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