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: 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.

A. Prepare to administer a vasopressor. B. Administer an anticholinesterase medication. C. Prepare the client for intubation. D. Instruct the client to perform pursed lip breathing.

Correct Answer is C

Explanation

The correct answer is: c. Prepare the client for intubation.

Choice A: Prepare to administer a vasopressor

Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.

Choice B: Administer an anticholinesterase medication

Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.

Choice C: Prepare the client for intubation

Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.

Choice D: Instruct the client to perform pursed lip breathing

Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.

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