Hesi Guillain Barre Syndrome

Which question should the nurse ask Amid to support Dx of GBS?
B. Have you had any type of cold or stomach flu in the last month?

Which assessment intervention will the nurse implement specifically for the diagnosis or GBS?
A. Deep tendon reflexes

What intervention will the nurse implement prior to this procedure?
C. Obtain informed consent

Which intervention will the nurse implement POST procedure?
D. Increase Amid’s fluid intake

Which action indicates the nurse understands muslim food and beverage preferences?
C. Notify the dietary department that Amid cannot eat pork.

Which statement by Amid reflects the muslim faith?
A. I must pray 5 times a day

What action should the nurse implement?
D. Notify the healthcare provider

How should the nurse respond?
D. He has muscle weakness traveling up his body

Which nursing diagnosis will take priority for Amid as the syndrome progresses?
D. Ineffective breathing pattern r/t muscle weakness

Which longterm goal is written for this nursing Dx?
B. Client has minimal muscle atrophy

Which intervention should the ICU nurse implement first?
C. Assess the respiratory status and pulse ox reading

Which intervention addressing the mechanical vent should be included in the care plan?
A. Alternate the position of the endotracheal tube in the mouth daily.

Which action should the nurse implement?
D. Acknowledge the wife’s fears and explain the ventilator

Which is the nurse’s best response?
B. I will ask yes or no questions and he can blink Y/N

List the order the nurse should implement the interventions:

Based on the ABG results, Which action should the nurse implement?
A. Continue to monitor Amid

Which intervention should be implemented first?
A. Check tubing for any kinks

How should the nurse respond?
C. If the tube stays in too long it may injure his vocal cords

Which intervention will the nurse implement when providing trach care?
C. Position the ventilator tubing to ensure minimal pulling on the tube

Which assessment data indicates the client is experiencing a complication secondary to the vent?
C. Client has asymmetrical chest expansion

Which action will the nurse implement?
D. Provide praise for performing the bath safely for Amid and the UAP

Which tasks can be delegated to the UAP?
A. Escort
B. Vitals

The nurse’s response will be based on which scientific rationale?
A. Full recovery occurs within several months to a year after onset of symptoms

Which referral is most important to implement upon Amid’s transfer to the rehab unit?
B. Physical Therapist

Which intervention should the nurse implement prior to Amid’s discharge from the rehab unit?
D. Demonstrate proper body mechanics to Amid’s wife and brother.

What is the nurse’s best response?
B. A visit to the mosque would be just fine, your faith is important.

Guillain-Barre Syndrome (GBS) – this disease develops in relation to acute destruction of the myelin sheath of peripheral nerves due to an autoimmune disorder that results in varying degrees of muscle weakness & paralysis?? – after the acute phase, remyelination …

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1. Which statement explains the mechanisms of action of Sinemet in the treatment of Parkinson’s disease? Sinemet is converted to dopamine and provides an exogenous form of dopamine replacement 2. How should the nurse respond? Instruct Nancy to bring Leo …

1. Which action will the nurse implement first since informed consent cannot be obtained? Prepare Hans for surgery and document that no family member is available. 2. What must the nurse do with Hans’ personal items? Assign two nurses to …

what is the best response by the nurse? “select whatever day you can best remember to perform BSE consistently each month.” what instructions should the nurse provide? “when you are lying down, your arm should be positioned over your head.” …

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