When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician?

A A report by the client of difficulty sleeping

B Removing the sequential compression device once a shift

C Hypoactive bowel sounds

D Glasgow Coma Score of 15

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Reporting difficulty sleeping may be important but is not typically a critical concern in Guillain-Barre Syndrome.

Choice B Rationale: Removing the sequential compression device once a shift may require clarification or education but is not a significant medical concern.

Choice C Rationale: Hypoactive bowel sounds can indicate a potential bowel obstruction or paralytic ileus, which is a significant medical concern in clients with Guillain-Barre Syndrome and should be reported to the physician.

Choice D Rationale: A Glasgow Coma Score of 15 is within the normal range and would not typically require reporting to the physician in the context of Guillain-Barre Syndrome.

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Correct Answer is D

Explanation

Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.

Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.

Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.

Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.

A. notify the nurse administrator B. clean up the spill C. Ask the client to remain still D. document the incident

Correct Answer is C

Explanation

Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.

Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.

Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.

Choice D Rationale: Documenting the incident is important but should follow

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When planning care for a client hospitalized with Guillain-Barre Syndrome, which of the following will the nurse report to the physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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