Author Question: Which assessment data for a patient who has Guillain-Barr syndrome will require the nurse's most ... (Read 40 times)

bobypop · **on:** Jun 25, 2018

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.

javimendoza7 · **Reply #1 on:** Jun 25, 2018

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.