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 A
Explanation
Choice A reason: Patient should increase daily iron supplements, is a statement that indicates a need for additional teaching. Iron supplements are not recommended for patients with beta-thalassemia, because they already have high levels of iron in their blood due to the frequent blood transfusions. Excess iron can cause damage to the liver, heart, and other organs. Therefore, the patient should avoid iron supplements and foods rich in iron, and take chelation therapy to remove the excess iron from the body.
Choice B reason: Signs and symptoms of infection, is a statement that does not indicate a need for additional teaching. Patients with beta-thalassemia are at risk of developing infections, due to the impaired immune system and the exposure to blood-borne pathogens. Therefore, the patient should be aware of the signs and symptoms of infection, such as fever, chills, sore throat, cough, or skin lesions, and seek medical attention promptly.
Choice C reason: Our child will need to have blood transfusions, is a statement that does not indicate a need for additional teaching. Blood transfusions are the main treatment for patients with beta-thalassemia, because they help to increase the level of hemoglobin and red blood cells, and prevent anemia and its complications. Therefore, the patient should receive regular blood transfusions, usually every two to four weeks, depending on the severity of the condition.
Choice D reason: Swimming is a good activity for our child, is a statement that does not indicate a need for additional teaching. Swimming is a good activity for patients with beta-thalassemia, because it helps to improve the cardiovascular fitness, muscle strength, and joint mobility, and reduce the stress and fatigue. Therefore, the patient should engage in moderate physical activities, such as swimming, walking, or cycling, as tolerated, and avoid strenuous or competitive sports that can cause injury or dehydration.
Correct Answer is B
Explanation
Choice A reason: "You need to bring your child to the emergency department immediately and have the stool tested for blood." is not an appropriate response by the nurse. Black stools can be a sign of gastrointestinal bleeding, which is a serious condition that requires immediate medical attention. However, in this case, the black stools are most likely caused by the iron supplement, which can change the color and consistency of the stool. Therefore, there is no need to panic or rush to the emergency department.
Choice B reason: "Greenish black stools are normal when oral iron supplements are being administered." is the most appropriate response by the nurse. It is a factual and reassuring statement that explains the reason for the stool color change and educates the mother about the expected side effect of the iron supplement. It also encourages the mother to continue the treatment for the child's anemia.
Choice C reason: "You should stop administering the daily iron supplement." is not an appropriate response by the nurse. It is a harmful and incorrect advice that contradicts the prescribed treatment for the child's anemia. Stopping the iron supplement can worsen the child's condition and lead to complications such as growth retardation, cognitive impairment, or heart failure.
Choice D reason: "Don't worry about it." is not an appropriate response by the nurse. It is a dismissive and vague statement that does not address the mother's concern or provide any information or education. It can also undermine the mother's trust and confidence in the nurse and the health care system.
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