An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?

Check the medication list for interactions.

Put the client on safety precautions

Place the client on a bed alarm.

Assess the client's oxygen saturation

Answer and Explanation

The Correct Answer is D

A. Check the medication list for interactions. While some medications can cause confusion or restlessness, the priority in Guillain-Barré syndrome (GBS) is to assess for respiratory compromise, as GBS can lead to progressive neuromuscular paralysis, affecting breathing. Reviewing medications is important but not the first action.
B. Put the client on safety precautions. Clients with confusion and restlessness may need fall precautions, but the priority concern in GBS is respiratory function. If hypoxia is causing confusion, addressing oxygenation takes precedence over safety measures.
C. Place the client on a bed alarm. A bed alarm can help prevent falls if the client is confused or restless, but it does not address the underlying cause of these symptoms. Hypoxia-related confusion must be ruled out first before focusing on fall prevention.
D. Assess the client's oxygen saturation. Respiratory failure is the most serious complication of Guillain-Barré syndrome due to progressive paralysis of the diaphragm and intercostal muscles. Restlessness and confusion can be early signs of hypoxia, making it critical to assess oxygenation immediately. If oxygen saturation is low, the nurse should provide supplemental oxygen and notify the provider for further intervention, such as respiratory support or mechanical ventilation if necessary.

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Correct Answer is A

Explanation

A: "Observe for facial symmetry while the client smiles." Facial symmetry assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Observing for symmetry during smiling allows the nurse to identify any weakness or paralysis that may indicate dysfunction of the nerve, which is crucial in diagnosing conditions such as Bell's palsy or other neurological disorders.
B: "Have the client identify specific smells." Identifying smells evaluates cranial nerve I (olfactory nerve), responsible for the sense of smell. Identifying specific odors tests olfactory function but does not provide information regarding cranial nerve VII, making it irrelevant for assessing facial nerve function.
C: "Whisper in one of the client's ears while occluding the other." Whispering in one ear while occluding the other tests cranial nerve VIII (vestibulocochlear nerve), involved in hearing and balance. While assessing hearing is important, it does not relate to cranial nerve VII, which focuses on facial muscle control and expression, rendering this action inappropriate for the examination of cranial nerve VII.
D: "Check the client's visual acuity using a Snellen chart." The Snellen chart assesses cranial nerve II (optic nerve), responsible for vision. Using a Snellen chart to measure visual acuity is unrelated to the function of cranial nerve VII and does not contribute to evaluating the facial nerve's integrity or function.

A. Cluster B. Tension-type C. Frontal-type D. Migraine

Correct Answer is D

Explanation

A: "Cluster." Cluster headaches are characterized by severe, unilateral pain, often described as sharp or burning rather than throbbing. They typically occur in cyclical patterns or clusters and are often accompanied by autonomic symptoms, such as nasal congestion or tearing, rather than photophobia.
B: "Tension-type." Tension-type headaches are generally bilateral and described as a dull, pressing, or tightening sensation rather than throbbing. They are not usually associated with photophobia or a family history of migraines, making this option less likely.
C: "Frontal-type." Frontal-type headaches can occur in the forehead area but do not have a specific classification as a primary headache type. They may be associated with sinus issues or tension but do not fit the description of unilateral, throbbing pain with photophobia or family history.
D: "Migraine." Migraines are typically unilateral and throbbing, often preceded by premonitory symptoms such as photophobia or aura. The association with family history suggests a genetic predisposition to migraines, further supporting this diagnosis.

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An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII?

Correct Answer is A

Explanation

Which type of headache would the nurse suspect when the headaches are unilateral and throbbing, preceded by a premonitory symptom of photophobia, and associated with a family history?

Correct Answer is D

Explanation

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