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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the dose of valproic acid oral solution, the nurse should use the following formula:
Dose (mL) = Ordered dose (mg) / Concentration (mg/mL) x Volume (mL)
Plugging in the values from the question, we get:
Dose (mL) = 500 mg / (250 mg / 5 mL) x 5 mL
Simplifying, we get:
Dose (mL) = 500 mg / 50 mg x 5 mL
Dose (mL) = 10 mL
Therefore, the nurse should administer 10 of valproic acid oral solution to the patient.
Correct Answer is C
Explanation
A. Hyperglycemia:
Hyperglycemia refers to high blood sugar levels. While certain medications can affect glucose metabolism and potentially lead to hyperglycemia as a side effect, this is not typically associated with hydantoin therapy for seizure disorder. Therefore, it is less likely for the patient to experience hyperglycemia as a direct result of taking hydantoin medication.
B. Hunger:
Hunger is not a common side effect of hydantoin therapy for seizure disorder. While some medications may affect appetite or cause changes in eating habits, hunger is not a typical side effect of hydantoin medications such as phenytoin.
C. Hypoglycemia:
Hypoglycemia refers to low blood sugar levels, which can lead to symptoms such as confusion, dizziness, sweating, and weakness. Hydantoin medications, particularly phenytoin, can affect glucose metabolism and increase the risk of hypoglycemia, especially in patients who already have diabetes or are prone to low blood sugar. Therefore, it is important for patients taking hydantoin therapy to monitor their blood sugar levels regularly and be aware of the signs and symptoms of hypoglycemia.
D. Pupil dilation:
Pupil dilation, or mydriasis, is not a common side effect of hydantoin therapy for seizure disorder. While certain medications may affect pupil size, this is not typically associated with hydantoin medications such as phenytoin.
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