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A client with Guillain-Barré syndrome reports increasing weakness in the legs. Which statement by the nurse describes this symptom?

A.

"The leg weakness is caused by reduced blood flow to the peripheral nerves."

B.

"The leg weakness is caused by psychological stress, temporarily affecting nerve function."

C.

"The leg weakness is caused by immune damage to the myelin sheath of the nerves."

D.

"The leg weakness is caused by prolonged immobility and muscle disuse."

Answer and Explanation

The Correct Answer is C

A. Reduced blood flow to peripheral nerves can cause ischemic neuropathy, but this is not the underlying mechanism in Guillain-Barré syndrome (GBS). Blood flow is typically adequate, and ischemia is not the primary cause of weakness.

B. Psychological stress may temporarily affect perception of strength or coordination, but GBS is an autoimmune neurological disorder with a physiological cause, not a psychosomatic one.

C. This is the correct explanation. Guillain-Barré syndrome is an acute autoimmune disorder in which the body’s immune system attacks the myelin sheath of peripheral nerves. Damage to myelin slows or blocks nerve signal transmission, leading to progressive, symmetrical weakness that typically begins in the legs and ascends upward. Explaining this mechanism helps the client understand the physiological basis of their symptoms.

D. Prolonged immobility and muscle disuse can lead to weakness over time (atrophy), but this is a secondary effect. The primary cause of acute leg weakness in GBS is demyelination of peripheral nerves, not disuse.


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Related Questions

Correct Answer is B

Explanation

A. While elevating the feet can relieve minor edema, this is not specifically related to dabigatran therapy. Dabigatran does not typically cause peripheral edema, and foot swelling is not the primary safety concern for this medication.

B. This is the most important instruction. Dabigatran etexilate is an anticoagulant (direct thrombin inhibitor) used to prevent stroke in clients with atrial fibrillation. Because it affects the blood’s ability to clot, clients are at increased risk for bleeding. Signs such as unexplained bruising, nosebleeds, gum bleeding, black or bloody stools, or prolonged bleeding from cuts must be reported immediately. Early recognition of bleeding complications is critical for preventing serious or life-threatening hemorrhage.

C. While blood pressure monitoring is important for overall cardiovascular health, dabigatran does not directly affect blood pressure. This instruction is not the priority safety teaching for this medication.

D. Monitoring pulse may be relevant for assessing atrial fibrillation control, but it does not address the primary safety concern of anticoagulation therapy.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

Rationales for Correct Answers:

  • Safety: According to Maslow’s Hierarchy of Needs and the nursing process, safety is always the highest priority for a psychiatric patient. While the client is not currently expressing suicidal ideation, the presence of worsening depressive symptoms over three years places her at a high risk for a safety crisis.
  • Report of hopelessness: In psychiatric nursing, hopelessness is a primary red flag and a major risk factor for suicide. It is a subjective state where the individual sees no alternative or way out of their current pain. Because the client describes a "growing sense of hopelessness" that has progressively worsened, it serves as the most critical evidence requiring safety-related follow-up.

Rationales for Incorrect Answers

  • Self-care deficit: While the client clearly has a self-care deficit (oily, matted hair; stained clothing), hygiene is considered a "lower-level" need compared to the immediate risk of self-harm or psychological collapse associated with safety.
  • Nutritional imbalance: The client's weight gain and carbohydrate cravings are characteristic of SAD, but they are not life-threatening. Metabolic needs are prioritized after safety and stability have been established.
  • Matted hair: This is objective evidence of a self-care deficit. While significant, it does not provide evidence for a safety priority as directly as a psychological report of hopelessness does.
  • Six-pound weight gain in 2 weeks: This is objective evidence of nutritional imbalance and is a physical manifestation of her depression. It does not indicate an immediate safety risk.

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