While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Profuse sweating.

Weakness in the lower legs.

Loss of sensation at T-8.

Leg pain that worsens at night.

Answer and Explanation

The Correct Answer is C

Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.

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Correct Answer is B

Explanation

Choice A rationale
A superficial partial-thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. The description provided does not match this type of burn.
Choice B rationale
A full-thickness burn involves total destruction of the epidermis and dermis, and in some cases, the underlying tissue, muscle, and bone. The description of the burn as severely swollen, with a wound bed that appears brown and yellow, and the patient reporting no pain, is consistent with a full-thickness burn.
Choice C rationale
A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. The description provided does not match this type of burn.
Choice D rationale
Deep full-thickness burns are a more severe form of full-thickness burns that extend beyond the dermis into deeper tissues. The description provided does not match this type of burn.

A. Call the PACU nurse to prepare for prolonged ventilatory support. B. Hold a prescription for dantrolene until the fever is reduced. C. Prepare ice packs for placement in the patient’s axillary area. D. Determine if prescribed antibiotics were administered preoperatively. E. None F. None

Correct Answer is C

Explanation

C. Prepare ice packs for placement in the patient’s axillary area.This response is crucial because the symptoms described—muscle rigidity and hyperthermia—are indicative ofmalignant hyperthermia, a serious reaction that can occur after the administration of succinylcholine, especially in conjunction with certain anesthetics. Immediate cooling measures, such as applying ice packs, are essential to help reduce the patient's elevated body temperature.

Rationale for Other Options:

A. Call the PACU nurse to prepare for prolonged ventilatory support.: While preparing for ventilatory support may be necessary later, immediate action to address hyperthermia is critical.
B. Hold a prescription for dantrolene until the fever is reduced.: Dantrolene is the antidote for malignant hyperthermia and should be administered as soon as possible rather than held.
D. Determine if prescribed antibiotics were administered preoperatively.: This action is not relevant to the immediate management of malignant hyperthermia.

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While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

Correct Answer is B

Explanation

A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?

Correct Answer is C

Explanation

Rationale for Other Options:

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