A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

"Have you had an MMR immunization?"

"Have you had a recent upper respiratory infection?"

"Have you traveled overseas recently?"

"Are you taking a multivitamin?"

Answer and Explanation

The Correct Answer is B

A. "Have you had an MMR immunization?"

This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.

B. "Have you had a recent upper respiratory infection?"

This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.

C. "Have you traveled overseas recently?"

While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.

D. "Are you taking a multivitamin?"

The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.

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Correct Answer is C

Explanation

A. Extension of the extremities

Extension of the extremities is not consistent with decorticate posturing. Instead, it is more indicative of decerebrate posturing, where both the upper and lower extremities are typically extended.

B. Pronation of the hands

Pronation of the hands is not typically associated with decorticate posturing. In decorticate posturing, the hands are usually flexed with the wrists and fingers pointing towards the body.

C. Plantar flexion of the legs

Plantar flexion of the legs characteristic of decorticate posturing. Decorticate posturing mainly involves plantar flexion of the feet.

D. External rotation of the lower extremities

External rotation of the lower extremities is also not typically associated with decorticate posturing. In decorticate posturing, the lower extremities may exhibit extension or internal rotation, but external rotation is not a characteristic feature.

A. Dizziness and problems with balance B. Slow papillary response to light C. Jerky eye movements D. Absence of the Achilles tendon jerk

Correct Answer is D

Explanation

A. Dizziness and problems with balance

While dizziness and problems with balance can occur more frequently in older adults due to age-related changes in the vestibular system and other factors, persistent or severe dizziness or balance issues should be evaluated further as they could indicate underlying neurological or medical conditions.

B. Slow papillary response to light

This finding may be considered abnormal, especially if it represents a significant change from the individual's baseline. While age-related changes in pupil function can occur, a slow or sluggish pupillary response to light may indicate dysfunction of the oculomotor nerve or other neurological issues and should be investigated further.

C. Jerky eye movements

Jerky eye movements, such as nystagmus, can be abnormal and may indicate dysfunction of the vestibular system or other neurological conditions. While some degree of nystagmus can occur with age, persistent or severe jerky eye movements should be evaluated further.

D. Absence of the Achilles tendon jerk

This finding may also be considered abnormal. The Achilles tendon reflex, tested using the deep tendon reflex (DTR) examination, can diminish with age but should not be completely absent in the absence of specific medical conditions affecting the reflex arc or spinal cord function.

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A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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