In caring for the child with Guillain-Barré syndrome the nurse will provide much supportive care while watching carefully for signs of deterioration in which body system?
Integumentary
Genitourinary
Respiratory
Cardiovascular
The Correct Answer is C
A. While skin care is part of overall nursing care, the integumentary system is not the primary concern in Guillain-Barré syndrome (GBS). Pressure injuries may occur if mobility is limited, but deterioration in this system is not life-threatening.
B. Bladder dysfunction can occur in GBS, but it is not usually the most critical system at risk for rapid deterioration. Nursing interventions may include monitoring urinary output and preventing urinary retention, but it is secondary to respiratory monitoring.
C. GBS often causes progressive muscle weakness, including the diaphragm and intercostal muscles, leading to respiratory compromise. The nurse must carefully monitor respiratory status, including respiratory rate, effort, oxygen saturation, and signs of hypoventilation, as respiratory failure is a major complication and can be life-threatening.
D. Cardiovascular complications such as autonomic dysfunction (e.g., fluctuations in blood pressure or heart rate) can occur in GBS, but the immediate priority is respiratory monitoring because respiratory failure can occur rapidly and requires urgent intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Pavlik harness is typically worn continuously, including during diaper changes, except when specifically instructed by the healthcare provider. Frequent removal can compromise hip positioning and reduce treatment effectiveness.
B. While some cases may require further intervention if the harness is unsuccessful, the Pavlik harness often is the primary treatment for infants with developmental dysplasia of the hip (DDH) under 6 months of age. This statement is misleading for parent teaching.
C. The Pavlik harness is generally worn for several weeks to months, depending on the infant’s response and severity of hip dysplasia. Two weeks is insufficient for proper hip stabilization.
D. The Pavlik harness is designed to hold the infant’s hips in flexion and abduction, promoting proper alignment of the femoral head in the acetabulum. This positioning allows the hip joint to develop normally and reduces the risk of long-term complications such as hip subluxation or dislocation. This statement accurately conveys the purpose of the device and is essential for parent education.
Correct Answer is A
Explanation
A. Myelomeningocele is a type of spina bifida in which a portion of the spinal cord and meninges protrude through a defect in the vertebral column. The exposed sac is fragile and at high risk for infection and trauma. Covering it with a sterile, saline-moistened dressing maintains moisture, prevents desiccation, and reduces the risk of infection. This is the highest priority nursing intervention prior to surgical repair.
B. While thermoregulation is important in newborns, preventing cold stress is secondary to protecting the integrity of the myelomeningocele sac. The sac’s protection and prevention of infection take priority over temperature control.
C. Leaving the sac exposed and dry increases the risk of rupture and infection, which can lead to severe complications including meningitis or neurological damage. This approach is unsafe and contrary to standard preoperative care guidelines.
D. Positioning an infant with myelomeningocele requires caution to avoid pressure on the sac. Typically, the infant is placed prone or on the side with careful padding to prevent sac trauma. Frequent repositioning without proper support could injure the sac. Therefore, routine side-to-side turning is not recommended until after surgical repair and stabilization.
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