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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A Reason:
Carbidopa/levodopa can cause the urine to turn a dark color, such as red, brown, or black. This is a harmless side effect but can be alarming to patients if they are not forewarned. Informing patients about this potential change helps to prevent unnecessary concern.
Choice B Reason:
Expecting immediate relief after taking carbidopa/levodopa is not accurate. While some patients may experience symptom relief relatively quickly, it often takes several weeks for the full therapeutic effects to be realized. Patients should be advised to continue taking the medication as prescribed and to communicate with their healthcare provider about their progress.
Choice C Reason:
Taking carbidopa/levodopa with high-protein food is not recommended. High-protein foods can interfere with the absorption of the medication, reducing its effectiveness. It is generally advised to take the medication on an empty stomach or with a low-protein snack.
Choice D Reason:
Skipping a dose of the medication if experiencing dizziness is not advisable. Dizziness can be a side effect of carbidopa/levodopa, but it should be managed by adjusting the dose or timing of the medication rather than skipping doses. Patients should discuss any side effects with their healthcare provider to find the best management strategy.
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