A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?
Are you taking a multivitamin?
Have you had a recent influenza infection?
Have you traveled overseas recently?
Do you have a history of chronic alcohol abuse?
The Correct Answer is B
Choice A reason: Asking about multivitamin intake is not directly relevant to GBS, as the syndrome is not known to be caused by vitamin deficiencies or related to nutritional status.
Choice B reason: A recent influenza infection is relevant because GBS is often preceded by an infection, such as a respiratory or gastrointestinal viral infection. The immune system's response to this infection may mistakenly attack peripheral nerves, leading to GBS.
Choice C reason: While travel history is important in assessing exposure to infectious diseases, it is less specific than asking about recent infections. GBS can occur after exposure to certain viruses or bacteria, which can be contracted without overseas travel.
Choice D reason: Chronic alcohol abuse is a risk factor for various neurological conditions, but it is not a typical precursor to GBS. The syndrome is more commonly associated with immune responses to infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.
Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.
Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.
Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.
Correct Answer is B
Explanation
Choice A reason: Establishing short-term, realistic goals is important, but it should come after assessing the client's current knowledge. Goals should be tailored to the individual's needs and understanding.
Choice B reason: Assessing the client's current knowledge about managing diabetes is crucial as the first step. This allows the nurse to identify any gaps in understanding and to provide education that is specific to the client's needs.
Choice C reason: Providing access to a video about diabetes can be a useful educational tool, but it should not be the first action. The content of the video may not address the client's specific questions or misconceptions.
Choice D reason: Evaluating the effectiveness of the client's admission teaching plan is an ongoing process and should be done after initial education and interventions have been provided.
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