Page 2063 - Saunders Comprehensive Review For NCLEX-RN

without turning the torso would contraindicate driving. Also note the closed-ended
word “only” in the correct option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Spinal cord injury
Priority Concepts: Client Education; Safety
Reference: Lewis et al. (2017), pp. 1427-1428.

723. Answer: 4

Rationale: The client with Guillain-Barré syndrome is at risk for respiratory
failure because of ascending paralysis. An intubation tray should be available for
use. Another complication of this syndrome is cardiac dysrhythmias, which
necessitates the use of electrocardiographic monitoring. Because the client is
immobilized, the nurse should assess for deep vein thrombosis and pulmonary
embolism routinely. Although items in the incorrect options may be used in care,
they are not the most essential items from the options provided.
Test-Taking Strategy: Note the strategic words, most essential. With an ascending
paralysis, the client is at risk for involvement of respiratory muscles and subsequent
respiratory failure. The correct option is the only one that includes an intubation
tray, which would be needed if the client’s status deteriorated to needing intubation
and mechanical ventilation. This option most directly addresses the airway.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Guillain-Barré syndrome
Priority Concepts: Clinical Judgment; Safety
Reference: Lewis et al. (2017), pp. 1440-1441.

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