The nurse is preparing a teaching session about Guillain-Barre syndrome. Which statement should be included in the presentation?
The disorder is commonly fatal.
The progressive muscle weakness will begin in the lower extremities and move upward.
The disorder is caused by a fungal infection.
The disorder's most significant manifestations are muscle pain and stiffness.
The Correct Answer is B
Choice A reason: The disorder is commonly fatal, is not a true statement. Guillain-Barre syndrome is a rare and serious condition that affects the peripheral nervous system. It causes inflammation and damage to the nerve fibers, leading to muscle weakness, numbness, and paralysis. However, most people recover from Guillain-Barre syndrome, although some may have long-term complications or disabilities. The mortality rate is about 4% to 7%.
Choice B reason: The progressive muscle weakness will begin in the lower extremities and move upward, is a true statement. Guillain-Barre syndrome usually starts with tingling and weakness in the feet and legs, and then spreads to the arms and upper body. This pattern of weakness is called ascending paralysis, and it can affect the breathing, swallowing, and facial muscles. The weakness usually reaches its peak within two to four weeks, and then gradually improves over months or years.
Choice C reason: The disorder is caused by a fungal infection, is not a true statement. Guillain-Barre syndrome is not caused by a fungal infection, but by an abnormal immune response. The exact cause of Guillain-Barre syndrome is unknown, but it is often preceded by an infection, such as a respiratory or gastrointestinal infection, or a vaccination. The immune system mistakenly attacks the nerve fibers, causing inflammation and damage.
Choice D reason: The disorder's most significant manifestations are muscle pain and stiffness, is not a true statement. Guillain-Barre syndrome's most significant manifestations are muscle weakness and paralysis, not pain and stiffness. Muscle pain and stiffness may occur in some cases, but they are not the main symptoms or the most serious ones. The weakness and paralysis can affect the vital functions, such as breathing, blood pressure, and heart rate, and require intensive care and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Sudden unconsciousness, unresponsiveness, and apnea are not typical symptoms of a brain tumor. They are more likely to indicate a stroke, seizure, or cardiac arrest.
Choice B reason: Increased temperature, blood pressure, heart rate, and respirations are not specific symptoms of a brain tumor. They are more likely to indicate an infection, inflammation, or stress.
Choice C reason: Changes in vision and personality, and headache upon awakening are common symptoms of a brain tumor. They are caused by the pressure of the tumor on the brain tissue and the cranial nerves.
Choice D reason: Fever, increased white blood cell count, and decreased appetite are not typical symptoms of a brain tumor. They are more likely to indicate a systemic infection or malignancy.
Correct Answer is C
Explanation
Choice A reason: Assessing the patient for potential visual deficits is not the primary purpose of evaluating pupillary response. Visual deficits may result from damage to the optic nerve or the occipital lobe, but they are not directly related to pupillary response.
Choice B reason: Assessing the patient's level of consciousness is an important part of the neurological assessment, but it is not done by evaluating pupillary response alone. Level of consciousness is determined by observing the patient's responsiveness to verbal and physical stimuli, as well as their orientation to person, place, time, and situation.
Choice C reason: Assessing the patient for increased intracranial pressure is the best explanation for evaluating pupillary response. Increased intracranial pressure is a life-threatening condition that can result from brain swelling, bleeding, or infection. It can cause compression of the brainstem and the cranial nerves, leading to changes in pupillary size, shape, and reactivity. Pupillary response is a sensitive indicator of intracranial pressure and brainstem function.
Choice D reason: Assessing the patient for cerebrospinal fluid leakage is not the main reason for evaluating pupillary response. Cerebrospinal fluid leakage can occur after a craniotomy due to a tear in the dura mater, the membrane that covers the brain and spinal cord. It can cause symptoms such as headache, nausea, vomiting, and meningitis. However, it does not affect pupillary response unless it causes increased intracranial pressure.
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