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

Choice A Reason

“Avoid strenuous activities for 1 week following the procedure.” This statement is partially correct. While it is advisable to avoid strenuous activities, the exact duration can vary. Typically, patients are advised to avoid heavy lifting and vigorous activities for a few days to a week, depending on their recovery.

Choice B Reason

“You will lie on your back during the procedure.” This statement is incorrect. For a bone marrow biopsy from the iliac crest, the patient usually lies on their side or stomach to allow access to the hip bone. Lying on the back would not provide the necessary access for the procedure.

Choice C Reason

“You will receive general anesthesia for the procedure.” This statement is incorrect. Bone marrow biopsies are usually performed under local anesthesia to numb the area. General anesthesia is not typically required. The patient may also receive a mild sedative to help them relax.

Choice D Reason

“Take acetaminophen as prescribed for pain relief after the procedure.” This is the correct statement. Acetaminophen is commonly recommended for pain relief after a bone marrow biopsy because it is effective and has fewer side effects compared to other pain medications like NSAIDs, which can increase the risk of bleeding.

Choice A Reason

Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.

Choice B Reason

Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.

Choice C Reason

Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.

Choice D Reason

Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.

Choice E Reason

Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.