PEDs Exam 3
The nurse is caring for a child who has just been admitted to the pediatric unit with sickle cell crisis. He is complaining that his right arm and leg hurt. What is the priority nursing intervention? A.) Administer pain medication every 3 hours intravenously until pain is controlled B.) Perform passive range of motion of the arm and leg to maintain function C.) Try acetaminophen for pain first, moving up to opioids only if needed D.) Use narcotic analgesics and warm compresses as needed to control the pain
A Rationale: The priority in a sickling crisis is to bring pain under control quickly as this brings the child relief; also, the significant stress resulting from pain can contribute to the further sickling of cells.
A 5-year old who had a renal transplant 9 months ago and has no history of chickenpox presents to the pediatric clinic for his vaccinations. Which is the most appropriate set to give? A. DTaP, IPV B.) DTaP, IPV, MMR, varicella C.) DTaP, IPV, varicella D.) IPV only
A Rationale: The routine schedule for healthy 4- to 6-year-olds includes DTaP, IPV, and MMR. If the child had not had chickenpox in the past and was unvaccinated, then varicella would also be warranted. The child in this case is taking chronic immunosuppressive medications for his renal transplant, however, and immunosuppression is a contraindication for live vaccine use (measles and varicella are live vaccines).
A mother brings her 6 month old infant to the clinic. The child has been vomiting since early morning and has had diarrhea since the day before. His temperature is 38 C, pulse 140, and respiratory rate 38. He has lost 6 oz since his well-child visit 4 days ago. He cries before passing a bowel movement. He will not breastfeed today. What is the priority nursing diagnosis? A.) Thermoregulation alteration B.) Pain (abdominal) related to diarrhea C.) Fluid volume deficit related to excessive losses and inadequate intake D.) Alteration in nutrition, less than body requirements, related to decreased oral intake
C Rationale: Infants are at significant risk for dehydration due to their increased proportion of body fluid as compared with adults. Although fever and pain are important, fluid volume takes priority in the infant with fluid losses or decreased intake.
A child with hemophilia fell while riding his bicycle. He was wearing a helmet and did not lose consciousness. He has a mild abrasion on his knee that is not oozing. He is complaining of abdominal pain. What is the priority nursing assessment? A.) Perform neurologic checks B.) ability to void frequently C.) Carefully assess his abdomen D.) Examine his knee frequently
C Rationale: The child's complaint of abdominal pain indicates that undetected bleeding may be present in the abdomen. Determining whether internal bleeding is present would take priority over the knee abrasion, which has nearly stopped bleeding.
T/F: Infants and young children display relatively smaller lymph nodes, tonsils, and thymus compared with adults.
False
True or False: Children with dark skin tend to have more pronounced cutaneous reactions compared to children with lighter skin.
False
True/False: Nursing interventions for a child with hydrocephalus include maintaining cerebral perfusion, administering intravenous antibiotics, and minimizing neurologic complications.
False
True/False: Palpation should be the first in the sequence of the abdominal examination.
False
The nurse is caring for a child who has had a renal transplant. The child weighs 47 lb. The medication order reads: cyclosporine 96 mg PO every 12 hours. Cyclosporine is supplied as 100 mg/mL. How many milliliters will the nurse administer? Round to the nearest whole number.
0.96 milliliters (ml)
Absence of bowel sounds can be determined after a _____ minute period of auscultation.
5
______________ is the most prevalent skin condition occurring in childhood.
Acne
T/F: A macule is a small raised bump on the skin.
False
Morbilliform refers to a rosy, _________ rash.
MACULOPAPULAR
T/F: All blood cells originate from a single type of cell called a multipotent stem cell.
True
T/F: The spleen is functional at birth.
True
True or False: Contact dermatitis is a cell-mediated response to an antigenic substance exposure.
True
Urticaria is commonly known as___________.
hives
The ___________ is the lower orifice of the stomach opening into the duodenum.
pylorus
A care plan for a child with neonatal seizures will include ensuring adequate __________, correcting any underlying metabolic disturbances, and administering anticonvulsant therapy.
ventilation
True or False: Enuresis refers to continued incontinence of urine past the age of toilet training.
True
True or False: Keloid formation occurs more often in dark-skinned children.
True
ITP is thought to be an immune response following a viral infection that produces ___________ antibodies.
antiplatelet
__________ agents are used in the treatment of a confirmed case of aseptic meningitis.
antivirals
Juvenile idiopathic arthritis is an autoimmune disorder in which the _________ mainly target the joints.
autoantibodies
Aplastic anemia refers to failure of the bone marrow to produce _______.
cells
Neurologic disorders result from __________ problems, infections, or traumas.
congenital
Decorticate posturing occurs with damage of the cerebral __________.
cortex
Sickle cell disease refers to a group of ________ hemoglobinopathies.
inherited
About one third of all children with urologic malformations are at high risk for the development of _____________ allergy.
latex
Complications of ________ poisoning include behavioral issues and learning difficulties and, at high levels, encephalopathy, seizures, and brain damage.
lead
The nurse should assess for hypoxia, fatigue, and ______ in the child with anemia
pallor
Physical examination of the genitourinary system includes inspection and observation, auscultation, __________, and palpation.
percussion
The nurse is caring for a child who is in status epilepticus. The child weighs 14.97 kg (33 lb). The medication order reads: Diazepam 3 mg IV push now. Per the Pediatric Dosage Handbook, the recommended dose is 0.1 to 0.3 mg/kg/dose. Diazepam is supplied as 5 mg/mL. How many milliliters will the nurse administer? Round to the nearest tenth.
0.6 milliliters (ml)
The nurse is caring for a 4-year-old with acute lymphoblastic leukemia. The child weighs 38 lb. The medication order reads: ondansetron 2.6 mg IV every 8 hours for chemotherapy-related nausea/vomiting. Ondansetron is supplied as 4 mg/2 mL. How many milliliters will the nurse administer? Round to the nearest tenth.
1.3 milliliters (ml)
The nurse is caring for a term newborn born to a mother with HIV infection. The infant weighs 6 lb 5 oz. The medication order reads: zidovudine 25 mg PO twice daily. Zidovudine is supplied as 50 mg/5 mL. How many milliliters will the nurse administer with each dose? Round to the nearest tenth.
2.5 milliliters (ml)
The nurse is caring for a child who has tinea corporis. The child weighs 18 lb 11 oz. The medication order reads: Griseofulvin 85 mg PO every day. Griseofulvin is supplied as 125 mg/5 mL. How many milliliters will the nurse administer? Round to the nearest tenth.
3.4 milliliters (ml)
A child is NPO during the preoperative period and requires IV fluid maintenance. The child weighs 31 lb 4 oz. What is the child's recommended hourly IV fluid rate?
50 mL/h
Critical Thinking: Sixteen-year-old Melody Carson is admitted to the pediatric intensive care unit after being a passenger in a car struck by a train. Two of her friends, also in the car, were killed in the accident. Melody is unconscious at this time. She also has a broken right femur, two broken ribs, and a fractured pelvis.
Assess: Glasgow Coma Scale Change in vital signs Indications of increased pain Restlessness Posturing Anticipate: Hemorrhage Cerebral edema Herniation Infection Education about Melody's injury and care Involving the family in the interdisciplinary team Involving the family in Melody's care Encouraging verbalization of their feelings and concerns
A 6-month-old infant is admitted to the hospital with suspected bacterial meningitis. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be: A.) Educate the family on ways to prevent bacterial meningitis. B.) Initiate appropriate isolation precautions and begin intravenous antibiotics. C.) Assess the infant's fontanels. D.) Encourage the mother to hold the infant and feed her.
B Rationale: Bacterial meningitis is a medical emergency and requires prompt hospitalization and treatment. Deterioration may be rapid and may occur in less than 24 hours, leading to long-term neurologic damage, and even death. Intravenous antibiotics will be started immediately after the LP and blood cultures have been obtained. Appropriate isolation needs to be initiated in any child with suspected or diagnosed bacterial meningitis.
A 14-year-old with systemic lupus erythematosus wants to know how to care for her skin. What should the nurse teach this adolescent? A.) Careful sun tanning will give her skin an attractive color. B.) No special skin care is needed. C.) Use sunscreen daily to avoid rashes. D.) Use makeup to camouflage the butterfly rash on her face.
C Rationale: Children with SLE experience photosensitivity that results in skin rashes. Daily sunscreen use (minimum SPF 15) is recommended.
A 5-year-old has been diagnosed with Wilms tumor. What is the priority nursing intervention for this child? A.) Educate the parents about dialysis, as the kidney will be removed B.) Measure abdominal girth every shift C.) Avoid palpating the child's abdomen D.) Monitor BUN and creatinine every 4 hours
C Rationale: Excessive palpation of the abdomen in a child with Wilms' tumor can cause seeding of the tumor, leading to metastasis.
The nurse is caring for a child in the emergency department who was bitten by the family dog, who is fully immunized. What is the priority nursing action? A.) Administer rabies immunoglobulin. B.) Refer the child to a counselor. C.) Assess the depth and extent of the wound. D.) Administer a tetanus booster.
C Rationale: Fully assess the extent of the wound before initiating other care. A full assessment allows the nurse to determine the next course of action.
A child with cancer is receiving chemotherapy, and his mother is concerned that the nausea and vomiting associated with chemotherapy are reducing his ability to eat and gain weight appropriately. What is the most appropriate nursing action? A.)Administer an antiemetic at the first hint of nausea B.) Offer the child's favorite foods to encourage him to eat C.) Start antiemetic drugs prior to the chemotherapy infusion D.) Maintain IV fluid infusion to avoid dehydration
C Rationale: Give the antiemetic prior to the chemotherapy drug to prevent nausea and vomiting.
A 10-year-old child is admitted to the hospital due to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention? A.) Prevention of injury by removing the child from his bed B.) Prevention of injury by placing a tongue blade in the child's mouth C.) Prevention of injury by restraining the child D.) Prevention of injury by placing the child on his side and opening his airway
D Rationale: Placing the child on his side and opening his airway can help prevent aspiration.
The nurse is caring for an infant on the pediatric unit who has a very red rash in the diaper area, with red lesions scattered on the abdomen and thighs. What is the priority nursing intervention? A.) Administer Griseofulvin with a fatty meal. B.) Institute contact isolation precautions. C.) Apply topical antibiotic cream. D.) Apply topical antifungal cream.
D Rationale: An angry red rash with satellite lesions is typical of diaper candidiasis. Topical antifungal preparations are indicated.
The nurse is performing education for the parents of an infant with bladder exstrophy. Which statement by the parents would indicate an understanding of the child's future care? A.) "Care will be no different than that of any other infant." B.) "My infant will only need this one surgery." C.) "My child will wear diapers all his life." D.) "We will need to care for the urinary diversion."
D Rationale: Management of exstrophy of the bladder requires some type of urinary diversion. It may be a continent, catheterizable stoma, or a stoma requiring pouching.
A child with leukemia has the following am laboratory results: Hgb 8.0, Hct 24.2, WBC 8,000, platelets 150,000. What is the priority nursing assessment? A.) Monitor for fever B.) Assess for bruising or bleeding C.) Determine intake and output D.) Assess for pallor, fatigue, and tachycardia
D Rationale: The Hgb and Hct indicate anemia, which results in fatigue, pallor, and tachycardia.
A 3-day-old infant presenting with physiologic jaundice is hospitalized and placed under phototherapy. Which response indicates to the nurse that the parent needs more teaching? A.) "My infant is at risk for dehydration." B.) "My infant needs to stay under the lights, except during feeding time." C.) "My infant can continue to breastfeed during this time." D.) "My infant has a serious liver disease."
D.) Rationale: Physiologic jaundice is a self-limiting disease without long-term effects on liver function.
Critical thinking: A 6-month-old baby is brought to the physician's office with a history of diarrhea. She has had six watery stools in the past 18 hours. She is vomiting her formula. Her mother states that she has had no fever. What indicated dehydration? What is the priority nursing diagnosis? What is the plan of care (including teaching)
Decrease in number of wet diapers, but otherwise normal examination findings (alert, oral mucosa moist and pink, skin pink with elastic turgor, fontanel soft and flat, normal pulse and blood pressure). deficient fluid volume The plan should include oral rehydration (intravenous rehydration is not necessary in the case of mild dehydration), with instructions for clear liquids (preferably an oral rehydration solution) for the first 8 to 24 hours (see Teaching Guidelines 41.1). When vomiting resolves, the diet should include complex carbohydrates and fats to increase transit time, provide nutrition, and bulk up the stools.
T/F: Hemoglobin is the percentage of red blood cells in the blood including serum.
False
Critical Thinking: A child is seen in the doctor's office after hitting his head while skateboarding. The child suffered no loss of consciousness, and has no external injuries and no significant past medical history. He is acting appropriately at this time. His only complaint is a dull headache. What instructions would you give the parents regarding his care at home? Include when they should seek further medical care.
Instruct parents or caregiver that a responsible adult must stay with the child for the next 24 hours and be ready to take the child to the hospital if necessary. The child may require close observation for a few days. Wake the child every 2 hours to ensure that he moves normally, wakes enough to recognize the caregiver, and responds to the caregiver appropriately. Instruct parents to call their medical provider or bring the child to the emergency room if: the child complains of a constant headache that gets worse; presents with slurred speech, dizziness that does not go away or happens repeatedly, or extreme irritability or other abnormal behavior; vomits more than twice; is clumsy or has difficulty walking; is oozing blood or watery fluid from the ears or nose; has difficulty waking up, unequal-sized pupils, or unusual paleness that lasts longer than 1 hour; or experiences any seizure activity.
The gastrointestinal tract includes all of the structures from the __________ to the anus.
Mouth
___________ is reddening of the skin.
Rosacia
Cellular immunity is mediated by the ___________.
T-cells
Critical Thinking: A 6-year-old child is admitted to the hospital because of a possible seizure. The child's mother calls the nurse to the room because the child is "jerking all over" and won't respond when she calls the child's name. List appropriate nursing interventions for this child. Prioritize the list of interventions.
The first priority will be to assess ABC's in the child then to prevent injury (loosen or remove tight clothing or necklaces if possible, turn child onto his side and open airway if possible, remove hazards). Time the seizure. Administer appropriate medication and treatments to stop seizure if ordered; remain calm and provide education and support to the child and family; provide appropriate documentation, including a description of behavior seen, length of seizure, and response to interventions.
Critical Thinking: Ricky Roberts, 2 years old, is brought to the emergency room by his parents and is actively having seizures. His mother tells the nurse that Ricky was diagnosed with epilepsy 6 months ago and that he has been having one seizure after another for the past 40 minutes. The mother states that Ricky has not regained consciousness in between seizures.
The nurse knows that status epilepticus is a medical emergency and the priority would be basic life support—maintaining the airway, followed by breathing and circulation. Further treatment would be to administer anticonvulsants to stop seizure activity. Padding of side rails and other hard objects Side rails raised on the bed at all times when the child is in bed Oxygen and suction at the bedside Supervision, especially during bathing, ambulation, or other potentially hazardous activities Use of a protective helmet during activity may be appropriate The child should wear a medical alert bracelet
True or False: Target lesions look like a bull's eye.
True
True or False: UTI occurs more frequently in males during infancy.
True
True/False: A family teaching plan for a child with epilepsy should include instructions for responding to seizures for parents, family, teachers, and day care workers.
True
True/False: Behavioral therapy and counseling may be necessary for children who have functional constipation and stool withholding.
True
True/False: Dehydration occurs more readily in infants and young children than it does in adults.
True
True/False: The small intestine is not fully functional at birth
True
True/False:Prematurity, difficult delivery, and infection during pregnancy are risk factors associated with neurologic disorders.
True
The nurse observes a child for neurologic disorders. What is the earliest indicator of improvement or deterioration of neurologic status? a. Vital signs b. Level of consciousness c. Motor function d. Reflexes
b. Level of consciousness. Level of consciousness is the earliest indicator of improvement or deterioration of neurologic status. Rationale: While all the choices may indicate deterioration of neurologic status, the level of consciousness is the first indicator of improvement or deterioration in neurologic status. Consciousness consists of alertness, which is a wakeful state and includes the ability to respond to stimuli, and cognition, which includes the ability to process stimuli and demonstrate a verbal or motor response.
A child on the pediatric unit has morning laboratory results of Hgb 10.0, Hct 30.2, WBC 24,000, and platelets 20,000. What is the priority nursing assessment? A.) Assess for pallor, fatigue, and tachycardia B.) Monitor for fever C.) Assess for bruising or bleeding D.) Determine intake and output
c Rationale: The extremely low platelet count places the child at significant risk for bleeding, so this takes priority over borderline anemia and possibility of infection.
The nurse is assisting with testing on a newborn suspected of having a neural tube defect. Which of the following diagnostic tests would be used to confirm this condition? a. Lumbar puncture b. Electroencephalogram c. Fluoroscopy d. Magnetic resonance imaging
d. Magnetic resonance imaging (MRI). MRI would be used to confirm a neural tube defect as it provides information about both the bony and soft tissues. Rationale: Lumbar puncture is used to measure ICP and obtain CSF samples. Electroencephalogram is used to diagnose seizures and brain death by measuring the electrical activity of the brain. Fluoroscopy assesses the cervical spine for instability during movement.
Epispadias refers to a urethral defect resulting in the opening occurring on the ________ surface of the penis.
dorsal
______________ is the inability to swallow or difficulty swallowing.
dysphagia
Nephrotic syndrome results in significant proteinuria and ______________.
edema
The parents of children with chronic neurologic disorders will require large amounts of __________ and support throughout the child's life time.
education
Hydrocele is characterized by ___________ in the scrotal sac.
fluid
Tinea is a term used to refer to a ___________ disease of the skin occurring on any part of the body.
fungal
Normal immune function is a complex process involving phagocytosis, ______ immunity, cellular immunity, and the activation of the complement system.
humoral
Critical Thinking: A 10-year-old child is admitted to the pediatric unit after experiencing a seizure. A complete, accurate, and detailed history from a reliable source is essential. What information would you ask for while obtaining the history?
When did the event occur---while sleeping, eating, playing, just after waking? Provide a description of the child's behavior during the event---what types of movements; progression and length of seizure; respiratory status; any apnea? How did the child behave after the event? Have the episodes been recurrent, and if so how frequent? Have there been any precipitating factors, such as a fever, fall, activity, anxiety, infection, or exposure to strong stimuli such as flashing lights or loud noises?"
At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds: A.) Narrow sutures B.) Sunken fontanels C.) A rapid increase in head circumference D.) Increase in weight since last visit
C Rationale: In the infant, the most obvious indication of hydrocephalus is often a rapid increase in head circumference. Assessment may also reveal bulging, tense fontanels with widening sutures.
Critical Thinking: A 14-kg child with moderate dehydration has received two boluses of normal saline in the emergency room prior to being admitted to the pediatric nursing unit. The physician orders D5 ½ NS @ 1½ maintenance. What is IV rate? What will the RN assess for to determine overhydration
50mL/hr Overhydration would be indicated by: Edema weight gain Tachycardia excessive output of dilute urine
A 3-month-old infant presents with a history of vomiting after feeding. The plan for the infant is to rule out GER. What information from the history would lead the nurse to believe that this infant may need further intervention? A.) Poor weight gain B.) Small "spits" after feeding C.) Sleeps through the night D.) Difficult to burp
A Rationale: GER is considered a routine and benign occurrence unless it is significant enough to cause respiratory symptoms or, as in this infant, to interfere with growth, in which case it would be considered gastroesophageal reflux disease, and would warrant treatment.
The nurse is caring for a child who has received significant partial-thickness burns to the lower body. What is the priority assessment in the first 24 hours after injury? A.) Fluid balance B.) Wound infection C.) Respiratory arrest D.) Separation anxiety
A Rationale: In the child with a serious burn, fluid balance is of priority importance in the first few days of care.
When compared with adults, why are infants and children at an increased risk of head trauma? A.) The head of the infant and young child is large in proportion to the body and the neck muscles are not well developed. B.) The development of the nervous system is complete at birth but remains immature. C.) The spine is very immobile in infants and young children. D.) The skull is more flexible due to the presence of sutures and fontanels.
A Rationale: Infants and young children have a larger head size in relation to the body and a higher center of gravity. Both cause them to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls.
The nurse is caring for a child who has had diarrhea and vomiting for the past several days. What is the priority nursing assessment? A.) Determine the child's weight B.) Ask if the family has traveled outside of the country C.) Assess circulation and perfusion D.) Send a stool specimen to the lab
C Rationale: Infants and children are at increased risk for dehydration and hypovolemia compared with adults. The nurse must quickly determine if the child with diarrhea and vomiting needs rehydration to prevent further (and usually quick) deterioration.
The nurse is caring for a 6-year-old with juvenile idiopathic arthritis. The mother states that she has trouble getting her daughter out of bed in the morning and believes the girl's behavior is due to a desire to avoid going to school. What is the best advice by the nurse? A.) Refer the girl to a psychologist for evaluation of school phobia related to chronic illness. B.)Administer a warm bath every morning before school. C.) Give the child her prescribed NSAIDs 30 minutes before getting out of bed. D.) Allow her to stay in bed some mornings if she wants.
B Rationale: Heat or warmth helps ease the stiffness resulting after a period of inactivity in a child with juvenile arthritis.
The nurse is teaching about skin care for atopic dermatitis. Which statement by the parent indicates that further teaching may be necessary? A.) "I will use Vaseline or Crisco to moisturize my child's skin." B.) "A hot bath will soothe my child's itching when it is severe." C.) "I will buy cotton rather than wool or synthetic clothing for my child." D.) "I will apply a small amount of the prescribed cream after the bath."
B Rationale: Hot baths should be avoided, as they are more dehydrating to the skin. Warm baths are preferred, followed by patting the child dry and rubbing on a small amount of prescribed cream, then a liberal amount of fragrance-free moisturizer. Wool clothing should be avoided in the child with atopic dermatitis.
A 4-year-old girl presents with recurrent urinary tract infection. A prior workup did not reveal any urinary tract abnormalities. What is the priority nursing action? A.) Obtain a sterile urine sample after completion of antibiotics. B.) Teach appropriate toileting hygiene. C.) Prepare the child for surgery to reimplant the ureters. D.) Administer antibiotics intramuscularly.
B Rationale: Inappropriate toileting hygiene is the cause of most UTIs in preschool girls. Although obtaining a urine specimen to insure eradication of bacteria after completion of the antibiotic course is important, the priority is with patient teaching. Infected urine may cause reflux and reflux may scar the kidneys, leading to hypertension later in life.
A varsity high-school wrestler presents with a "rug burn" type of rash on his shoulder that is not healing as expected, despite use of triple antibiotic cream. Two other wrestlers on his team have a similar abrasion. What infection should the nurse be most concerned about, based on the history? A.) Tinea cruris B.)MRSA C.) Impetigo D.) Tinea versicolor
B Rationale: MRSA may be nonresponsive to antibiotic ointments and is becoming common in the community, particularly among athletes. Impetigo is a possibility, although it is usually responsive to antibiotic cream. Tinea cruris and tinea versicolor also would not improve with an antibiotic cream, as they are fungal infections, but the description of the skin lesion does not fit.
A child presents with a 2-day history of fever, abdominal pain, occasional vomiting, and decreased oral intake. Which finding would the nurse prioritize for immediate reporting to the provider? A.) Temperature 101.9° F B.) Rebound tenderness and abdominal guarding C.) Parents will be leaving the child alone in the hospital D.) Child can tolerate only sips of fluid without nausea
B Rationale: Rebound pain and abdominal guarding are signs of an acute abdomen and should be reported immediately to the physician; surgery may be needed.
When the nurse is caring for a child with hemolytic-uremic syndrome or acute glomerulonephritis and the child is not yet toilet trained, which action by the nurse would best determine fluid retention? A.) Test urine for specific gravity. B.) Weigh child daily. C.) Weigh the wet diapers. D.) Measure abdominal girth daily.
B Rationale: The most accurate measure for determining fluid retention (or loss) is daily weight measured on the same scale, at the same time, in similar clothing or naked.
A 14-year-old with thalassemia asks for your assistance in choosing her afternoon snack. Which choice is the most appropriate? A.) Peanut butter with rice cake B.)Small spinach salad C.) Apple slices with cheddar cheese D.) Small burger on wheat bun
C Rationale: Children with thalassemia should avoid foods that are high in iron. Spinach, peanut butter, a burger, and whole-grain bread are high in iron. Apples and cheese are not.
What is the priority nursing intervention for the child recently admitted with Guillain-Barré syndrome? A.) Perform range-of-motion exercises. B.) Take temperature every 4 hours. C.) Monitor respiratory status closely. D.) Assess skin frequently.
C Rationale: Although range of motion and skin integrity are also important, the progressive paralysis associated with Guillain-Barré syndrome may lead to respiratory distress/arrest, so monitoring for respiratory involvement is critical.
