A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysi
a. Swallowing ability
b. Parental involvement
c. Level of consciousness
d. Antecedent viral infections
ANS: A
Assessment of swallowing is essential. Both pharyngeal involvement and respiratory function are usually involved at the same time. The child may require ventilatory support. The inability to swallow also contributes to aspiration pneumonia. Parental involvement is important after the physiologic assessment is complete. The child is answering questions and describing the onset of the illness, which demonstrates she is alert and oriented. Information regarding antecedent viral infections can be obtained after the child is assessed and stabilized.
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A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for further teaching?
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A 52-year-old male enters a sleep study to gather information about his sleep disturbances. He reports that his wife will not let him sleep in the bed with her until he stops snoring so loudly. He also reports feeling tired a lot through the day
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A) "How is it going?" B) "You say you aren't concerned, but you've asked me many questions on this same subject." C) "What do you mean when you say...?" D) "For now, I would like to concentrate on..."