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: 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.
Correct Answer is A
Explanation
Choice A reason: Immunoglobulin E (IgE) is associated with allergic reactions. A RAST test measures the level of allergen specific IgE antibodies in the blood. An elevation in IgE indicates sensitization to a particular allergen and a positive result for the allergy.
Choice B reason: Immunoglobulin M (IgM) is usually the first antibody produced by the immune system when it detects an infection. It is not typically associated with the detection of allergies.
Choice C reason: Immunoglobulin A (IgA) plays a critical role in mucosal immunity and is found in high concentrations in the mucous membranes, particularly those lining the respiratory passages and the gastrointestinal tract, but it is not used as an indicator in RAST testing for allergies.
Choice D reason: Immunoglobulin G (IgG) is the most abundant type of antibody and is involved in the recognition and removal of pathogens. It is not specific to allergic response detection in RAST testing.
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