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 B
Explanation
Choice A reason: Decreasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is not associated with decreasing intracranial pressure, but rather with increased pressure or brainstem compression.
Choice B reason: Increasing intracranial pressure with decorticate posturing is the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is associated with increased intracranial pressure or lesions in the cerebral hemispheres.
Choice C reason: Decreasing intracranial pressure with decorticate posturing is not the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is not associated with decreasing intracranial pressure, but rather with increased pressure or lesions in the cerebral hemispheres.
Choice D reason: Increasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is associated with increased intracranial pressure or brainstem compression, but it is not the posture described in the question.
Correct Answer is B
Explanation
Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.
Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.
Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.
Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.
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