In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?
Ascending muscle weakness
Difficulty with urination
Ptosis and diplopia
Ear distortion and pain
The Correct Answer is A
Choice A rationale
Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.9 "]
Explanation
Step 1: We are instructed to administer tobramycin 35mg IM every 8 hours. The available supply is 40mg in a 1 mL vial.
Step 2: We need to find out how many mL’s should the nurse administer. Step 3: We can set up a proportion to solve this.
Step 4: If 40mg is equivalent to 1mL, then 35mg is equivalent to x mL. Step 5: Solving for x gives us x = (35mg ÷ 40mg) × 1mL.
Step 6: Calculating the above expression gives us x = 0.875 mL.
Step 7: Rounding our answer to the nearest tenth, we get 0.9 mL. So, the nurse should administer 0.9 mL.
Correct Answer is A
Explanation
Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.
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