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?

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Avoiding driving in winter is not necessary unless it is a personal trigger for Raynaud's attacks. It's more important to keep warm and manage stress.

Choice B reason: Stress management classes can teach techniques to control stress, which is beneficial for clients with Raynaud's disease as stress can trigger episodes.

Choice C reason: Using nicotine gum to quit smoking is a positive step for overall health, but it is not directly related to the management of Raynaud's disease.

Choice D reason: Limiting coffee intake may help some individuals with Raynaud's disease, as caffeine can constrict blood vessels, but it is not a universal recommendation.

A. Oral temperature of 38.2°C (100.76°F). B. Output of burgundy colored urine. C. An urge to void despite having an indwelling urinary catheter. D. Pulse rate of 58/min.

Correct Answer is B

Explanation

Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.

Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.

Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.

Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.

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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?

Nursing Test Bank

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