A 27-year-old patient is hospitalized with new onset of ...

[kwoodring]

A 27-year-old patient is hospitalized with new onset of Guillain-Barr syndrome. The most essential assessment for the nurse to carry out is
 
  a. determining level of consciousness.
  b. checking strength of the extremities.
  c. observing respiratory rate and effort.
  d. monitoring the cardiac rate and rhythm.

Question 2

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury?
 
  a. Cardiac monitoring for bradycardia
  b. Assessment of respiratory rate and effort
  c. Application of pneumatic compression devices to legs
  d. Administration of methylprednisolone (Solu-Medrol) infusion

[Jane]

Answer to Question 1

ANS: C
The most serious complication of Guillain-Barr syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.

Answer to Question 2

ANS: B
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

[kwoodring]

Thanks for the timely response, appreciate it

[peter]

Gracias!