A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Decreasing leg strength

Decreasing voice volume

Decreased deep tendon reflexes

Decreased sensation in the arms

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.

Choice B Reason:

Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.

Choice C Reason:

Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.

Choice D Reason:

Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.

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Correct Answer is D

Explanation

Choice A Reason:

Taking medicine with orange juice is not recommended for clients with GERD. Citrus juices, including orange juice, are highly acidic and can exacerbate GERD symptoms by increasing stomach acidity and causing reflux.

Choice B Reason:

A bedtime snack is likely to worsen heartburn rather than prevent it. Eating close to bedtime can increase the likelihood of acid reflux during the night, as lying down soon after eating can cause stomach contents to flow back into the esophagus.

Choice C Reason:

Lying down after meals is not advisable for clients with GERD. It is recommended to remain upright for at least 2-3 hours after eating to help prevent acid reflux. Lying down can increase the risk of stomach acid flowing back into the esophagus.

Choice D Reason:

Limiting activities that require bending at the waist is a good practice for managing GERD. Bending over can increase abdominal pressure and promote acid reflux. Instead, clients should try to bend at the knees or avoid such activities when possible.

A. Red B. Yellow C. Green D. Black

Correct Answer is A

Explanation

Choice A Reason:

A red tag is used to label those who cannot survive without immediate treatment but who have a chance of survival. The child’s respiratory rate of 8/min, unresponsiveness to verbal commands, and groaning to painful stimuli indicate severe injuries that require urgent medical attention. Immediate intervention is necessary to address potential life-threatening conditions.

Choice B Reason:

A yellow tag is assigned to those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. Given the child’s critical condition, a yellow tag would not be appropriate as it suggests the child can wait for treatment, which is not the case here.

Choice C Reason:

A green tag is for the “walking wounded” who will need medical care at some point after more critical injuries have been treated. This tag is not suitable for the child in question, as their condition is far from minor and requires immediate attention.

Choice D Reason:

A black tag is used for the deceased or those whose injuries are so severe that they are not expected to survive despite receiving care. While the child’s condition is critical, they still have a chance of survival with immediate treatment, making a black tag inappropriate.

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A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?

Correct Answer is D

Explanation

A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Correct Answer is A

Explanation

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