A nurse educator is providing an educational in-service about various neurological disorders. Which statement should be included when teaching about Guillain-Barre Syndrome?

Client's Response to Nitroglycerin Therapy

• Unstable Angina:
o Typically, unstable angina responds well to nitroglycerin. The relief of discomfort after nitroglycerin administration suggests that the chest pain was likely related to unstable angina, as it indicates a reduction in coronary artery spasm or temporary ischemia.
• Myocardial Infarction:
o In an MI, nitroglycerin may help alleviate pain, but it does not address the underlying cause of myocardial injury. The pain relief in an MI is generally more variable and may not be as effective if there is significant myocardial damage.

2. Client's Initial Report of Manifestations

• Unstable Angina:
o The symptoms described (shortness of breath, dizziness, and discomfort in the jaw, neck, and left arm) are consistent with unstable angina, which is characterized by episodes of chest pain or discomfort at rest or with minimal exertion, often associated with transient ischemia.
• Myocardial Infarction:
o These symptoms can also be consistent with MI, especially if they are severe or persistent. However, MI often presents with more intense and prolonged pain, and the discomfort might not always resolve with rest.

3. 12 Lead EKG Report

• Unstable Angina:
o ST depression on an EKG is more commonly associated with unstable angina, which indicates transient ischemia rather than a sustained myocardial injury.
• Myocardial Infarction:
o ST depression indicates ischemia commonly in angina.

4. Troponin Results

• Unstable Angina:
o Troponin levels are typically normal in unstable angina. The client’s troponin I (0.01 ng/mL) and troponin T (0.03 ng/mL) are within the normal range, suggesting no significant myocardial injury. This is consistent with unstable angina.
• Myocardial Infarction:
o Elevated troponin levels are a key marker of myocardial injury. The normal troponin results in this case do not support an MI diagnosis, as elevated troponin levels would be expected in MI.

A. This blood pressure and heart rate are within normal ranges for most patients. For example, a blood pressure of 132/60 mmHg is slightly elevated on the systolic side but not critically so, and a heart rate of 90 beats per minute is within the normal range (60-100 beats per minute).
B. Continuous bladder irrigation is used to prevent clots and debris from obstructing the urinary tract after a TURP. If the output from the Foley catheter has stopped, it may indicate a blockage or clot in the catheter or bladder, which can lead to bladder distension, discomfort, and potential kidney damage.
Immediate reporting to the provider is crucial because this could indicate a severe complication.
C. Pain levels are subjective, and a pain level of 5/10 indicates moderate discomfort. While pain management is important, a pain level of 5/10 is not unusual after TURP, and it can often be managed with appropriate pain relief measures.
D. Pink-colored urine is not uncommon immediately following a TURP as a result of bleeding or irritation from the procedure. This finding can be expected and may not indicate an immediate complication.
However, if the urine color changes to bright red or if there is a significant increase in blood, it could be more concerning.