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 D
Explanation
Choice A Reason
Maintain strict bed rest. This intervention is not typically recommended for managing Ménière’s disease. While rest during acute vertigo episodes is important, strict bed rest is not necessary and can lead to other complications such as muscle atrophy and decreased mobility.
Choice B Reason
Restrict fluid intake to the morning hours. This statement is incorrect. Fluid intake should be evenly distributed throughout the day to help manage the symptoms of Ménière’s disease. Restricting fluids to the morning hours can lead to dehydration and does not effectively manage the condition.
Choice C Reason
Administer aspirin. This intervention is not recommended for Ménière’s disease. Aspirin can worsen tinnitus, a common symptom of Ménière’s disease, and is generally avoided in these patients.
Choice D Reason
Provide a low-sodium diet. This is the correct intervention. A low-sodium diet helps reduce fluid retention in the body, which can decrease the pressure in the inner ear and help manage the symptoms of Ménière’s disease. Reducing sodium intake to 1,500-2,000 milligrams per day is often recommended.
Correct Answer is C
Explanation
Choice A Reason
The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.
Choice B Reason
The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.
Choice C Reason
The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.
Choice D Reason
The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.
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