The mother of a teenage client diagnosed with Guillian-Barre ...

[james9437]

The mother of a teenage client diagnosed with Guillian-Barre syndrome asks the nurse why the client keeps asking for her socks to be removed when the client is not wearing any socks.
 
  The nurse should instruct the mother in which of the following? 1. There is a change in sensation, and it feels like the client is wearing socks.
   2. Tactile hallucinations are part of the disorder.
   3. Medications are causing the client feel like socks are being worn.
   4. Confusion is a part of the disorder, and the client just thinks socks are on the feet.

Question 2

A client with a history of latex allergies develops audible wheezing, pruritus, urticaria, and signs of angioedema. Which of the following would the nurse perform initially?
 
  1. Administer epinephrine 1:100,000 IV per the health care provider's orders
   2. Collect a detailed history from the client regarding the history of latex allergies
   3. Teach the client regarding using a kit that contains treatment for allergic reactions
   4. Administer diphenhydramine (Benadryl) by mouth every four hours per the health care provider's orders

[ttt030911]

Answer to Question 1

1. There is a change in sensation, and it feels like the client is wearing socks.

Rationale:
With Guillain-Barr syndrome, there is frequently a stockingglove patternfeeling as though stockings and gloves are being worn when they are notwith pain in the hands, feet, and legs. This is what the nurse should instruct the mother. Tactile hallucinations are not part of the disorder. Medications are not causing the client to feel like socks are being worn. Confusion is not part of the disorder.

Answer to Question 2

1. Administer epinephrine 1:100,000 IV per the health care provider's orders
Rationale:
For mild reactions with wheezing, pruritus, urticaria, and angioedema, a subcutaneous injection of 0.30.5 mL of 1:1,000 epinephrine is generally sufficient. The nurse should give the epinephrine first due to the symptoms. Intravenous epinephrine using a 1:100,000 concentrations may be used in the client with a more severe anaphylactic reaction. The nurse does not have time to collect a detailed history because of the severity of the client's signs and symptoms. Clients who have experienced an anaphylactic reaction to insect venom or another potentially unavoidable allergen should carry a bee sting kit.