Author Question: A nurse is caring for an 8-year-old with Guillain-Barr Syndrome (GBS). On hourly rounds, the nurse ... (Read 23 times)

gbarreiro · **on:** Jun 28, 2018

A nurse is caring for an 8-year-old with Guillain-Barr Syndrome (GBS). On hourly rounds, the nurse assesses that the child's lung sounds are diminished, respiratory rate is 8 breaths/min and shallow, and pulse oximeter is 88.

What action by the nurse takes priority?
A.
Administer high-flow oxygen by mask.
B.
Call the rapid response team; prepare for intubation.
C.
Encourage the patient to take slow, deep breaths.
D.
Have the patient use the incentive spirometer.

Question 2

A health-care provider administers edrophonium (Tensilon) to a school-age child with new onset of muscle weakness. The child is able to hold her eyes open for the duration of the drug's half-life.

Which information does the nurse plan to teach the child and parents?
A.
Muscle weakness will progress in an ascending fashion.
B.
Pain control will be an important aspect of the child's care.
C.
This disease is a result of a previous viral infection.
D.
Weakness and fatigue will probably be worse during the day.

wtf444 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
In GBS, respiratory muscles can be affected, leading to respiratory failure. The nurse needs to prepare for intubation. The child's muscles are too weak for oxygen or the spirometer to help her, and she may be too weak to use the spirometer or to take deep breaths.

Answer to Question 2

ANS: D
A positive result to a Tensilon test is diagnostic for myasthenia gravis, an autoimmune disease uncommon in children. Muscle weakness is the main symptom, and the weakness is particularly pronounced in muscles used for eye movement, chewing, swallowing, and breathing. Weakness is usually worse during the day or during times of stress. It is not painful, muscle weakness does not progress in ascending fashion as in Guillain-Barr syndrome, and the cause is unknown.