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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Polyuria:
Polyuria, or increased urine output, is not typically associated with increased intracranial pressure. It may occur due to other factors such as diabetes insipidus or fluid administration.
B. Battle's sign:
Battle's sign refers to bruising behind the ear and is often associated with basilar skull fractures. While it can indicate a head injury, it is not a direct manifestation of increased intracranial pressure.
C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck muscles, is commonly associated with meningitis rather than increased intracranial pressure. It is a sign of meningeal irritation and inflammation rather than direct pressure within the skull.
D. Lethargy:
This is the correct answer. Lethargy, or excessive drowsiness or fatigue, can be an early manifestation of increased intracranial pressure. As pressure increases within the skull, it can lead to alterations in consciousness ranging from lethargy to coma. Monitoring the client for changes in level of consciousness, including lethargy, is important for early detection of increased intracranial pressure.
Correct Answer is B
Explanation
A. Intellectual capacity is not affected:
This statement refers to the fact that ALS primarily affects motor neurons, leading to muscle weakness and paralysis, but it typically does not directly impact cognitive function or intellectual capacity. While cognitive impairment is not a hallmark feature of ALS, some individuals may experience changes in cognitive function or behavior, such as executive dysfunction or frontotemporal dementia, in later stages of the disease. However, depression in ALS is not primarily linked to changes in intellectual capacity but rather to other factors such as altered communication, physical limitations, and loss of autonomy.
B. Communication is altered:
ALS can affect the muscles involved in speech and swallowing, leading to difficulties in communicationAs the disease progresses, patients may experience dysarthria (difficulty speaking clearly) and dysphagia (difficulty swallowing), which can impair their ability to communicate effectively with others. Altered communication can result in frustration, social isolation, and feelings of being misunderstood, all of which are risk factors for depression.
C. Mobility is limited:
ALS causes progressive muscle weakness and paralysis, which can significantly impair mobility over time. As the disease advances, individuals with ALS may become increasingly dependent on mobility aids such as wheelchairs or may require assistance with mobility tasks. Limited mobility can lead to feelings of loss of independence, decreased participation in activities, and increased dependence on caregivers, all of which can contribute to depression.
D. Nutritional intake is poor:
ALS can affect the muscles involved in swallowing and chewing, leading to difficulties with eating and drinking. Dysphagia, or difficulty swallowing, is a common symptom in ALS and can result in poor nutritional intake and weight loss. Malnutrition and weight loss are associated with increased morbidity and mortality in ALS, and they can also contribute to feelings of weakness, fatigue, and overall decline in quality of life, which may exacerbate depression.
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