The client recently diagnosed with Guillain-Barre' syndrome is drooling and having difficulty swallowing secretions. When asked why this is happening, which of the following is the best answer for the nurse to give to the family?
The disorder causes enlargement of parotid and salivary glands
It is caused by obstructed blood flow to the brain
The client has a deficiency of thiamine and pyridoxine in the central nervous system
Cranial nerves responsible for the swallow and the gag reflex have been affected by demyelination caused by the disorder
The Correct Answer is D
Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.
Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.
Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.
Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Hemiplegia involves paralysis of one side of the body and is typically associated with brain injuries or lesions, not spinal cord injuries.
Choice B Rationale: Quadriplegia involves paralysis of all four limbs and is more commonly associated with higher spinal cord injuries, not T2-T3.
Choice C Rationale: Paresthesia refers to abnormal sensations, such as tingling or numbness, and may be present in various spinal cord injuries, but it is not a type of disability.
Choice D Rationale: Paraplegia involves paralysis of the lower extremities and trunk, and it is commonly associated with spinal cord injuries at the T2-T3 level.
Correct Answer is D
Explanation
Choice A Rationale: Documenting an overdose is premature without further assessment and evidence.
Choice B Rationale: Acute dementia is not typically diagnosed based on rapidly fluctuating moods alone, and it may not be appropriate for this situation.
Choice C Rationale: While substance abuse comorbidity may be present, it does not fully capture the client's current presentation.
Choice D Rationale: Documenting acute delirium is appropriate in this case. The client's symptoms, including rapidly fluctuating moods and delusions, are indicative of acute delirium, which can be related to substance withdrawal or other medical issues.
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