Author Question: A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving ... (Read 56 times)

nenivikky · **on:** Jun 25, 2018

A client with Guillain-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?

a. Anxiety
b. Low fluid volume
c. Inadequate airway
d. Potential for skin breakdown

Question 2

The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the nurse is most important?

a. Administering anxiolytics
b. Having a ventilator nearby
c. Obtaining atropine sulfate
d. Sedating the client

diesoon · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

Answer to Question 2

ANS: C
Atropine is the antidote to edrophonium chloride and should be readily available when a client is having a Tensilon test. The nurse would not want to give medications that might cause increased weakness or sedation. A ventilator is not necessary to have nearby, although emergency equipment should be available.