a female client is admitted with a tentative diagnosis of guillain barre syndrome which finding is most important for the nurse to report to the healt
Logo

Nursing Elites

HESI RN

Community Health HESI

1. A female client is admitted with a tentative diagnosis of Guillain-Barre syndrome. Which finding is most important for the nurse to report to the healthcare provider?

Correct answer: B

Rationale: In Guillain-Barre syndrome, decreased deep tendon reflexes are a critical finding that may indicate impending respiratory failure. This is due to the involvement of the peripheral nervous system affecting the muscles, including those involved in breathing. Reporting decreased deep tendon reflexes promptly is essential to prevent respiratory compromise. Facial weakness, difficulty speaking, and inability to move the eyes are common manifestations of Guillain-Barre syndrome but are not as immediately concerning as respiratory distress and impending respiratory failure.

2. A client with a history of heart failure is admitted with severe dyspnea. Which laboratory result requires immediate intervention?

Correct answer: C

Rationale: The correct answer is C. A serum creatinine level of 1.0 mg/dL is within the normal range. However, in a client with heart failure and severe dyspnea, fluid retention is a significant concern. An elevated serum creatinine level may indicate impaired kidney function, which can worsen fluid overload. Therefore, immediate intervention is required to prevent further complications. Choices A, B, and D are within normal ranges and not indicative of immediate intervention in this scenario.

3. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

4. Which client has the highest risk for developing community-acquired pneumonia?

Correct answer: C

Rationale: The correct answer is C, a 60-year-old homeless person who is an alcoholic and smokes. This client has the highest risk of developing community-acquired pneumonia due to multiple factors such as homelessness, substance abuse, and smoking. Homelessness can lead to poor living conditions and limited access to healthcare, increasing susceptibility to infections. Alcoholism and smoking weaken the immune system, making individuals more vulnerable to respiratory infections like pneumonia. Choices A, B, and D do not present the same level of risk factors for pneumonia compared to choice C.

5. A graduate nursing student requests information, including laboratory findings and chest x-ray results, about all clients with symptoms of H1N1 who have been seen during the last month in a community health clinic. Which action should the charge nurse take?

Correct answer: C

Rationale: The correct action for the charge nurse to take is to obtain written authorization from clients to release the information. This step is crucial to ensure compliance with privacy laws and ethical standards. Asking for permission from the research committee (Choice A) may not address the individual clients' rights to privacy. Asking the student to sign a standard waiver form (Choice B) is not appropriate, as the authorization should come from the clients themselves. Providing the information for research purposes only (Choice D) without proper authorization violates client confidentiality and privacy.

Similar Questions

The school nurse is coaching a group of high school students on ways to deal with the stress of final exams. Today the class is focusing on healthy food choices for lunch in the school cafeteria. Which option should the nurse recommend?
Prior to implementing a community health program targeting teenage smoking, which information is most important for the nurse to obtain?
A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses