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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Free Nursing Study Resources

Correct Answer is D

Explanation

A: "Observing for facial symmetry." Facial symmetry evaluates cranial nerve VII (facial nerve), which is responsible for controlling the muscles of facial expression. While facial symmetry is an important aspect of a neurological examination, it does not relate to cranial nerve III, which has different functions.
B: "Eliciting the gag reflex." The gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus). The gag reflex is essential for assessing the integrity of these nerves, which play a role in swallowing and the gag response, but it is not relevant to cranial nerve III.
C: "Testing visual acuity." Visual acuity primarily assesses cranial nerve II (optic nerve), which is responsible for vision. While checking visual acuity is crucial for a comprehensive neurological examination, it does not evaluate cranial nerve III, which has functions related to eye movement and pupil response.
D: "Checking the pupillary response to light." Pupillary response directly assesses cranial nerve III (oculomotor nerve), which controls the muscles that constrict the pupils and move the eyes. Evaluating the pupillary response to light involves shining a light into each eye and observing the constriction of the pupil. A normal response indicates that the oculomotor nerve is functioning properly, while an abnormal response may suggest potential neurological issues, such as increased intracranial pressure or damage to the nerve itself. This assessment is vital for understanding the client's neurological status.

A. Protection of the eye on paralyzed side B. Provision of a fan to cool the face C. Medication for pain relief D. Precautions against aspiration

Correct Answer is A

Explanation

A. Protection of the eye on paralyzed side. Bell's palsy causes unilateral facial paralysis due to inflammation of cranial nerve VII (facial nerve), affecting eyelid closure. Clients are at risk for corneal drying and injury due to incomplete blinking and lagophthalmos (inability to close the eye completely). Nursing interventions include applying artificial tears, taping the eyelid shut at night, and using an eye patch or protective glasses to prevent corneal abrasions and ulcers.
B. Provision of a fan to cool the face. Clients with Bell's palsy often experience facial nerve sensitivity. Exposure to cold air or wind can trigger pain and muscle spasms, making a fan inappropriate. Instead, keeping the face warm and avoiding drafts can help reduce discomfort.
C. Medication for pain relief. Pain is not a primary symptom of Bell's palsy, though some clients may experience mild facial discomfort or headaches. While analgesics (e.g., NSAIDs) may be used for mild pain, the main focus of treatment is corticosteroids to reduce inflammation and protect facial nerve function.
D. Precautions against aspiration. Bell’s palsy does not affect swallowing function because it involves cranial nerve VII (facial nerve), not cranial nerves IX and X (which control swallowing). Clients may have drooling due to facial muscle weakness, but aspiration precautions are not typically necessary unless another neurological issue is present.

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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 assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is D

Explanation

A patient was diagnosed with Bell's palsy. Which intervention should the nurse include in the care of this patient?

Correct Answer is A

Explanation

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