A nurse is caring for a client that has been recently diagnosed with Guillian-Barre syndrome. What would the nurse consider to be common risk factors associated with Guillain-Barré syndrome (GB5)? (select all that apply)
Associated with recent vaccination
Associated with tobacco use
Recent surgical experience
Presence of a thymus gland
Associated with exposure to a recent viral infection
Correct Answer : A,C,E
A) Associated with recent vaccination:
Vaccinations, particularly those for influenza and other viral infections, have been linked to an increased risk of GBS in some cases. This association is believed to be due to an immune response that may trigger the autoimmune attack on the peripheral nervous system, leading to GBS.
B) Associated with tobacco use:
While smoking has been associated with various health conditions, including respiratory and cardiovascular diseases, there is no established direct link between tobacco use and the development of GBS. The pathophysiology of GBS is more strongly related to infections and certain immune responses rather than lifestyle factors like smoking.
C) Recent surgical experience:
It is believed that the stress from surgery, particularly in the presence of an infection or immune response, may trigger the development of GBS. Infections, especially bacterial infections like those caused by Campylobacter jejuni, which is a common antecedent of GBS, can sometimes occur after surgery.
D) Presence of a thymus gland:
The thymus is involved in the immune system, particularly in the development of T-cells, but there is no direct correlation between the thymus gland and the onset of GBS. GBS is more closely related to infections (viral or bacterial), recent vaccinations, or surgery rather than anatomical features like the thymus.
E) Associated with exposure to a recent viral infection:
Viral infections such as Zika virus, Epstein-Barr virus, cytomegalovirus (CMV), influenza, and others can trigger an autoimmune response that leads to the development of GBS. Infections are the most common precipitating factor for GBS, and the immune system’s response to the viral infection may cause the body to mistakenly attack its own peripheral nerves, leading to the symptoms of GBS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Intense pruritus (itching) noted during the assessment of the moles: While intense itching can be associated with skin changes and should be monitored, it is not a definitive sign of malignancy. However, it can be an early indicator that warrants further investigation, especially if accompanied by other changes in the mole.
B. Purulent drainage coming out of the moles: Purulent drainage typically indicates an infection rather than malignancy. While infections are serious and require treatment, they are not usually linked to skin cancer. This finding should prompt further assessment and appropriate wound care.
C. A healed sore noted upon assessment: A healed sore generally indicates that the area has resolved and is not immediately concerning. However, a non-healing or recurrent sore could be a sign of skin cancer and would need further evaluation by a healthcare provider.
D. The mole is larger than 6mm: A mole larger than 6mm is a significant indicator for potential malignancy, as size is one of the criteria in the ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) used for identifying melanoma. Larger moles warrant further examination to rule out skin cancer.
Correct Answer is B
Explanation
A) Obtain blood specimen for a BMP test:
Although obtaining laboratory tests like a BMP (Basic Metabolic Panel) can be important in evaluating the client’s electrolyte balance and kidney function, it is not the priority intervention in this acute situation. The client is exhibiting a potentially dangerous rhythm and the immediate intervention to stabilize the rhythm is necessary before ordering lab tests.
B) Prepare for synchronized cardioversion:
The priority intervention for a client exhibiting this cardiac rhythm with accompanying signs of hemodynamic instability (low blood pressure, tachycardia, respiratory distress) is synchronized cardioversion. This is especially the case if the rhythm is atrial fibrillation, atrial flutter, or supraventricular tachycardia (SVT), which can be life-threatening if not treated promptly. Synchronized cardioversion is indicated when the patient is symptomatic and hemodynamically unstable.
C) Start CPR:
While starting CPR is critical for a patient who is unresponsive and in a pulseless rhythm (such as ventricular fibrillation or asystole), this client is still responsive with a pulse of 130 bpm. Although the client is in a high-risk rhythm with signs of hemodynamic instability, CPR is not indicated at this moment because the client is not in cardiac arrest.
D) Prepare for defibrillation:
Defibrillation is indicated for life-threatening arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. In this case, the client has a pulse, indicating that defibrillation is not appropriate.
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