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.
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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.
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