A nurse is assessing a client who has Guillain-Barre Syndrome, and notes that the client's breathing is shallow and the client is short of breath. The nurse understands that that the client's respiratory distress is caused by which of the following?
Degeneration of nerves in the brainstem and spinal cord.
Pleural effusion caused by immobility.
Demyelination of nerves that stimulate the respiratory muscles.
Bronchoconstriction and edema of the airways.
The Correct Answer is C
A. While GBS primarily affects peripheral nerves (nerves outside the brain and spinal cord), it does not typically cause direct degeneration of nerves in the brainstem and spinal cord. Therefore, this option is not correct in the context of respiratory distress in GBS.
B. Pleural effusion caused by immobility: Pleural effusion, an accumulation of fluid in the pleural cavity around the lungs, is not a typical complication of GBS. It is more commonly associated with conditions such as heart failure, pneumonia, or malignancy, rather than directly with GBS.
C. In Guillain-Barre Syndrome, demyelination of nerves affects the transmission of signals from the brain to the muscles, including those responsible for respiration. As a result, respiratory muscles may become weak or paralyzed, leading to shallow breathing and respiratory distress.
D. While respiratory distress can occur in some neurological conditions due to autonomic dysfunction or secondary complications, such as aspiration pneumonia, bronchoconstriction and airway edema are not typical manifestations of GBS itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The soles of the feet are not typically assessed for cyanosis because they are not a reliable indicator of central cyanosis. Cyanosis is best evaluated in areas where mucous membranes are visible.
B. Similar to the soles of the feet, the palms of the hands are not a reliable indicator of central cyanosis. Cyanosis is not typically visible on the palms unless there are severe systemic circulation issues.
C. The oral mucosa (inside the mouth) is a reliable area to assess for central cyanosis. The nurse can inspect the lips, tongue, and buccal mucosa for a bluish discoloration, which indicates decreased arterial oxygen saturation.
D. The nail beds are also a reliable indicator of central cyanosis. The nurse can assess the color of the nail beds and look for bluish discoloration, which can be more apparent in darker-skinned individuals compared to the lips and oral mucosa.
Correct Answer is C
Explanation
A. Moon face is a common side effect of prednisone, a corticosteroid medication. It results from fluid retention and redistribution of fat in the face. While moon face is a cosmetic concern, it is not typically an urgent or critical finding that requires immediate reporting.
B. Muscle spasticity may develop but does not pose an immediate risk that requires urgent attention.
C. Alcohol consumption can interact with both prednisone and interferon B-1a, potentially leading to increased drug levels in the bloodstream and intensifying side effects. This interaction can also increase the risk of liver problems, which is particularly concerning given that interferon B-1a may cause liver issues.
D. Birth control pills have been a subject of debate regarding their effect on multiple sclerosis but a study found that oral hormonal contraceptives did not appear to be associated with an increased chance of MS relapses.
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