While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?
Irregular heart rate.
Profuse diaphoresis.
Lower leg weakness.
Full facial flushing.
The Correct Answer is A
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Explaining the procedure and obtaining the signature is the provider’s responsibility, not the practical nurse’s.
B. Checking the medical record for a signed consent form is part of the practical nurse’s verification role but does not address assessing client understanding.
C. Obtaining consent from a family member is only appropriate if the client is unable to provide it; otherwise, consent must come directly from the client.
D. The practical nurse is responsible for ensuring the client understands the procedure and the purpose of the consent form, reinforcing the provider’s explanation and promoting informed consent.
Correct Answer is A
Explanation
This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.
The other options are not correct because:
B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.
C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.
D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.
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