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. Defibrillation is not typically indicated for atrial fibrillation. Atrial fibrillation involves disorganized electrical activity in the atria rather than a shockable rhythm like ventricular fibrillation or ventricular tachycardia. Therefore, emergency defibrillation is not appropriate for a client with persistent atrial fibrillation.
B. CABG is a surgical procedure used to improve blood flow to the heart muscle by bypassing blocked coronary arteries. It is primarily indicated for clients with significant coronary artery disease that cannot be managed effectively with medications or less invasive
C. Anticoagulant therapy, such as with medications like warfarin or direct oral anticoagulants (DOACs), is crucial for clients with atrial fibrillation. AFib predisposes individuals to an increased risk of stroke due to the potential formation of blood clots in the atria. Anticoagulants help prevent clot formation and reduce the risk of stroke.
D. Diuretics are medications that increase urine output and are often used to manage fluid overload or congestion in conditions such as heart failure or volume overload. However, diuretic therapy alone does not address the underlying rhythm abnormality of atrial fibrillation.
Correct Answer is B
Explanation
A. Whole milk contains saturated fats, which can contribute to overall cardiovascular health risks. However, it's not directly linked to causing PACs. While reducing saturated fat intake is generally beneficial for heart health, whole milk alone might not significantly exacerbate PACs compared to other dietary factors.
B. Black tea contains caffeine, which is a stimulant that can potentially increase heart rate and trigger PACs or other irregular heart rhythms in sensitive individuals. Therefore, black tea is a consideration for clients with PACs as it can be a potential trigger.
C. Bacon is high in saturated fat and sodium, which can contribute to cardiovascular risks and overall heart health concerns. High-fat foods like bacon can indirectly influence heart rhythms, but there's not a direct correlation between consuming bacon and PACs.
D. Eggs and cheese are high in saturated fats and cholesterol, which can impact cardiovascular health. While not directly linked to causing PACs, the high-fat content of scrambled eggs with cheese may contribute to overall heart health concerns.
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