This topic contains a solution. Click here to go to the answer

Author Question: Which assessment data for a patient who has Guillain-Barr syndrome will require the nurse's most ... (Read 90 times)

bobypop

  • Hero Member
  • *****
  • Posts: 539
Which assessment data for a patient who has Guillain-Barr syndrome will require the nurse's most immediate action?
 
  a. The patient's triceps reflexes are absent.
  b. The patient is continuously drooling saliva.
  c. The patient complains of severe pain in the feet.
  d. The patient's blood pressure (BP) is 150/82 mm Hg.

Question 2

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?
 
  a. Support selection of a high-protein diet.
  b. Discuss options for sexuality and fertility.
  c. Assist in planning a prescribed bowel program.
  d. Use quad coughing to strengthen cough efforts.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

javimendoza7

  • Sr. Member
  • ****
  • Posts: 293
Answer to Question 1

ANS: B
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barr syndrome.

Answer to Question 2

ANS: C
Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.




bobypop

  • Member
  • Posts: 539
Reply 2 on: Jun 25, 2018
Thanks for the timely response, appreciate it


gcook

  • Member
  • Posts: 343
Reply 3 on: Yesterday
Excellent

 

Did you know?

Excessive alcohol use costs the country approximately $235 billion every year.

Did you know?

Elderly adults are at greatest risk of stroke and myocardial infarction and have the most to gain from prophylaxis. Patients ages 60 to 80 years with blood pressures above 160/90 mm Hg should benefit from antihypertensive treatment.

Did you know?

Approximately one in three babies in the United States is now delivered by cesarean section. The number of cesarean sections in the United States has risen 46% since 1996.

Did you know?

Human kidneys will clean about 1 million gallons of blood in an average lifetime.

Did you know?

Always store hazardous household chemicals in their original containers out of reach of children. These include bleach, paint, strippers and products containing turpentine, garden chemicals, oven cleaners, fondue fuels, nail polish, and nail polish remover.

For a complete list of videos, visit our video library