The nurse is admitting a school-age child with suspected ...

[chads108]

The nurse is admitting a school-age child with suspected Guillain-Barr syndrome (GBS). Which nursing intervention is a priority in the care for this child?
 
  a. Monitoring intake and output c. Placing on a telemetry monitor
  b. Assessing respiratory efforts d. Obtaining laboratory studies

Question 2

The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which interventions should the nurse plan for the care of the myelomeningocele sac?
 
  a. Open to air
  b. Covered with a sterile, moist, nonadherent dressing
  c. Reinforcement of the original dressing if drainage noted
  d. A diaper secured over the dressing

[verrinzo]

Answer to Question 1

ANS: B
Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, administration of intravenous immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Monitoring intake and output, telemetry monitoring, and obtaining laboratory studies may be part of the plan of care but are not the priority.

Answer to Question 2

ANS: B
Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.