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 B

Explanation

Choice A Rationale: Anticipating intubation is not warranted solely based on an O2 saturation of 92% and without further assessment.

Choice B Rationale: Asking the client to cough, then inhale and exhale deeply is an appropriate initial action to improve oxygenation and assess the client's respiratory status.

Choice C Rationale: Inserting an intravenous catheter is unrelated to the client's O2 saturation and would not address the immediate concern.

Choice D Rationale: Administering antihypertensives is not indicated based on the O2 saturation level, and it may not be safe without further assessment.

A. Stage 3 B. Stage 2 C. Stage 1 D. Early stage

Correct Answer is D

Explanation

Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.

Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.

Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.

Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.

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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

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?

Correct Answer is B

Explanation

During a client interview, the nurse notices that the client often fills in information with made-up stories. Which stage of Alzheimer's disease will the nurse see this behavior?

Correct Answer is D

Explanation

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