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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Rationale: The patient who developed a new cough after eating breakfast should be seen first. This sudden change in respiratory status during or after eating suggests a potential risk of aspiration, which requires immediate assessment and intervention to prevent respiratory distress or pneumonia.

Choice B Rationale: Medication refusal, while important, is not an immediate life threatening issue compared to a new cough with the potential for aspiration.

Choice C Rationale: Although constipation can be uncomfortable, it is not an acute priority compared to a new cough that may indicate a respiratory problem.

Choice D Rationale: A stage II pressure ulcer on the coccyx, while concerning, is not an immediate priority over a potential respiratory issue that requires urgent attention.

A. Stage 3 B. Stage 2 C. Stage 1 D. Early stage

Correct Answer is D

Explanation

Choice A Rationale: Stage 3 of Alzheimer's disease is characterized by increased memory deficits, but the behavior of filling in information with made-up stories is more commonly associated with the earlier stages.

Choice B Rationale: Stage 2 of Alzheimer's disease involves progressive cognitive decline but may not necessarily manifest with the specific behavior described.

Choice C Rationale: Stage 1 of Alzheimer's disease typically has mild cognitive changes, but the behavior mentioned is more indicative of the later stages.

Choice D Rationale: The early stage of Alzheimer's disease may involve the emergence of confabulation, where clients fill in gaps in memory with fabricated stories or information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving change-of-shift report for clients on the memory unit, which patient will the nurse see first?

Correct Answer is A

Explanation

During a client interview, the nurse notices that the client often fills in information with made-up stories. Which stage of Alzheimer's disease will the nurse see this behavior?

Correct Answer is D

Explanation

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