HESI Case Study Guillain-Barré Syndrome Questions and Answers

HESI Case Study Guillain-Barré Syndrome Questions and Answers 1. What information from the client would support the diagnosis of Guillain-BarrÉ syndrome? Any type of cold or stomach virus in the last month. 2. Which assessment intervention will the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? Assess deep tendon reflexes. 3. Which intervention will the nurse implement prior to this procedure? Obtain informed consent. 4. Which intervention should the nurse implement post-procedure? Increase client's fluid intake. 5. Which action indicates the nurse understands his Muslim food and beverage preferences? Notify the dietary department that the client cannot eat any pork. The nurse asks client, "How can the healthcare team best support your faith while you are in the hospital?" 6. Which statement by the client reflects his Muslim faith? I must be able to pray 5 times a day. The nurse is transcribing the healthcare provider's admitting orders. The nurse is having difficulty reading one of the orders. 7. Which action should the nurse implement? Notify the HCP immediately to clarify the order. Later during the shift, the nurse enters client's room and meets his brother and client's spouse. Client's brother states, "My brother tells me he has a syndrome but can't explain to me what is going on, can you tell me what is wrong with him?" 8. How should the nurse respond? Report that the client has muscle weakness that is traveling up his body and that it may get worse. 9. Which problem area will take priority for client as the syndrome progresses? Respiratory issues due to progressive muscle weakness. The nurse includes the identified problem for safety due to muscle weakness and fall risk in the plan of care. 10. Which long-term goal is applicable for this issue? The client will have minimal muscle atrophy? Two days after admission, client starts complaining of difficulty breathing. His numbness is ascending up his body and affecting his respiratory muscles. He is transferred to the Intensive Care Unit (ICU) and placed on a ventilator for respiratory support. 11. Which intervention will the Intensive Care Unit (ICU) nurse implement first? Assess the respiratory status and pulse oximeter reading. 12. Which intervention addressing the mechanical ventilator should be included in the nursing care plan? Alternate the position of the endotracheal (ET) tube in the mouth daily. After client is settled and resting comfortably in the ICU, the nurse escorts client's spouse and brother into his room. Client's eyes are open, and he is aware of what is going on around him. His spouse starts crying uncontrollably, which causes client to start fighting the ventilator and crying as well. 13. Which action should the nurse implement? Acknowledge the wife's fears and explain about the ventilator and machines. After client quits fighting the ventilator, his brother asks the nurse, "How will you communicate with my brother?" 14. What is the nurse's best response? The client will be asked yes or no questions and he can blink once for no and twice for yes. During the night shift, client starts having difficulty breathing. The nurse checks the ventilator and realizes something is wrong but is unable to fix the problem. Client is in obvious acute respiratory distress. 15. List the order of interventions the nurse should implement. (Place in numerical order from first action through last action.) 1. Ventilate with a manual resuscitation bag. 2. Notify the respiratory therapist. 3. Request stat arterial blood gases. 4. Auscultate the clients lung sounds. The ABG results are pH 7.38, PaO2 92 mm Hg (12.25 kPa), PaCO2 38 mm Hg (5.05 kPa), and HCO3 24 mEq/L (mmol/L). 16. Based on evaluation of the ABG results, which action will the nurse implement? Continue to monitor client without taking any action. Two hours after client is placed back on the ventilator the machine alarm goes off and there is an increase in the peak airway pressure. 17. Which intervention will the nurse implement first? Check the tubing for any kinks. Ten days later client is still receiving mechanical ventilation via the endotracheal tube. The healthcare provider has determined that client will need a tracheostomy since it is not known how much longer he will require ventilator support. Client's brother asks, "Why does he need to have this procedure? Is he getting worse?" 18. How should the nurse respond? "If the tube stays in his mouth too long it may injure his vocal cords. 19. Which intervention will the nurse implement when providing tracheostomy care? Position the ventilator tubing to ensure minimal pulling on the tube. 20. Which assessment data would indicate the client is experiencing a complication secondary to the ventilator? The client has asymmetrical chest expansion. Client is transferred to the medical floor. The unlicensed assistive personnel (UAP) is bathing the client with the bed in a high position with the opposite side rail raised. 21. Which action will the nurse implement? Provide praise for performing the bath safely for client and the UAP. 22. Which nursing task(s) can be safely delegated to the (UAP)? (Select all that apply. One, some, or all options may be correct.) Escort a client in a wheel chair to the hospital patio area. Take vital signs on an elderly client recovering from hip replacement surgery. The nurse assesses client and performs bedtime care. His spouse asks the nurse, "How long before my husband is back to normal? I miss him so much." 23. The nurse's response will be based on which scientific rationale. Full recovery usually occurs within several months to a year after onset of symptoms. 24. Which referral is most important for the rehabilitation nurse case manager to implement initially upon client's transfer to the rehab unit? Physical therapist. 25. Which intervention should the nurse implement prior to his discharge from the rehabilitation unit? Demonstrate proper body mechanics to his wife and brother. The day for client's discharge has finally arrived. The nurse escorts the client, along with his spouse and brother, to the car. Client asks the nurse, "May I visit the mosque on my way home?" 26. What is the best response by the nurse? Agree that a visit to the mosque would be fine acknowledging that the client's faith is important to him.