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: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.
Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.
Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.
Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.
Correct Answer is D
Explanation
Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.
Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.
Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.
Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today