A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Decreasing leg strength

Decreasing voice volume

Decreased deep tendon reflexes

Decreased sensation in the arms

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.

Choice B Reason:

Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.

Choice C Reason:

Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.

Choice D Reason:

Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.

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Correct Answer is A

Explanation

Choice A Reason

Review the client’s Hgb level prior to administration. This is the correct action. Monitoring hemoglobin (Hgb) levels is crucial before administering epoetin because it helps determine the appropriate dosage and ensures the treatment is safe and effective. Epoetin is used to stimulate red blood cell production, and administering it without checking Hgb levels can lead to complications such as hypertension or thromboembolic events if the Hgb level is too high.

Choice B Reason

Use the Z-track method when administering the medication. This statement is incorrect. The Z-track method is used for intramuscular injections to prevent medication from leaking into subcutaneous tissues. Epoetin is typically administered subcutaneously or intravenously, not intramuscularly, so the Z-track method is not applicable.

Choice C Reason

Shake the vial for 30 seconds prior to withdrawing the medication. This statement is incorrect. Shaking the vial of epoetin can damage the protein structure of the medication, rendering it ineffective. The vial should be gently swirled if necessary, but not shaken.

Choice D Reason

Ensure the client is not taking iron supplements while on this medication. This statement is incorrect. Iron supplements are often necessary when administering epoetin because iron is required for the production of hemoglobin. Ensuring adequate iron levels helps maximize the effectiveness of epoetin therapy.

A. Expressive aphasia B. Poor impulse control C. Left hemiparesis D. Disorientation to place

Correct Answer is A

Explanation

Choice A Reason

Expressive aphasia is a common symptom of a left-hemisphere stroke. This condition, also known as Broca’s aphasia, affects the ability to produce language, making it difficult for the patient to speak fluently. The patient may understand speech but struggle to form coherent sentences, often speaking in short, choppy phrases.

Choice B Reason

Poor impulse control is more commonly associated with right-hemisphere strokes. The right hemisphere of the brain is responsible for controlling impulsive behavior and emotional regulation. Therefore, this symptom is less likely to be observed in a patient with a left-hemisphere stroke.

Choice C Reason

Left hemiparesis refers to weakness on the left side of the body. Since the left hemisphere of the brain controls the right side of the body, a left-hemisphere stroke typically results in right-sided weakness or paralysis. Therefore, left hemiparesis is not a typical finding in this scenario.

Choice D Reason

Disorientation to place can occur after a stroke, but it is not specifically associated with left-hemisphere strokes. Disorientation is a general symptom that can result from various types of brain injuries and is not exclusive to strokes affecting the left hemisphere.

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A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is A

Explanation

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