The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?
Increased pulse rate, adventitious breath sounds.
Increased pulse rate, respirations of 16 breaths/minute.
Decreased pulse rate, respirations of 20 breaths/minute.
Decreased pulse rate, abdominal breathing.
The Correct Answer is A
Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Exposing the affected area to air. To maintain skin integrity, the nurse should advise the client to expose the affected area to air.
Barrier garments, such as liners and protective pants, can trap moisture and irritate the skin, which can lead to skin breakdown. Exposing the affected area to air can help keep the skin dry and prevent skin breakdown.
B is not the correct answer because the application of moisture sealant can help protect the skin and prevent skin breakdown.
C is not the correct answer because using an electric room deodorizer is not related to maintaining skin integrity.
Correct Answer is C
Explanation
Allow the client to follow your lead. This technique would be most beneficial for the ambulation of a visually impaired client. The nurse should allow the client to follow their lead because they are more familiar with their surroundings and can navigate better.
Option A, speaking before touching the client, is appropriate but not as effective as allowing the client to follow the nurse's lead.
Option B, providing a see-eye guide dog, may not always be feasible.
Option D, providing a detailed description of the room and walkway, may be helpful but not as effective as allowing the client to follow the nurse's lead.
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