A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?
Decreasing leg strength
Decreasing voice volume
Decreased deep tendon reflexes
Decreased sensation in the arms
The Correct Answer is B
Choice A Reason:
Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.
Choice B Reason:
Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.
Choice C Reason:
Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.
Choice D Reason:
Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason
Request a prescription for an antibiotic. This intervention is not typically included in the standard care plan for all COPD patients. Antibiotics are generally reserved for cases of acute exacerbations of COPD (AECOPD) with signs of bacterial infection, such as increased dyspnea, increased sputum purulence, and increased sputum volume. Routine use of antibiotics without these signs is not recommended.
Choice B Reason
Educate the client on pursed-lip breathing. This is the correct intervention. Pursed-lip breathing is a technique that helps improve ventilation, release trapped air in the lungs, and reduce the work of breathing. It is particularly beneficial for patients with COPD as it helps them manage shortness of breath and improve their breathing efficiency.
Choice C Reason
Place the client on airborne precautions. This intervention is incorrect. COPD is not an infectious disease that requires airborne precautions. Airborne precautions are used for diseases that are transmitted through the air, such as tuberculosis. COPD management focuses on improving lung function and preventing exacerbations.
Choice D Reason
Initiate oxygen therapy for SpO₂ of 92%. This intervention is partially correct but needs clarification. Oxygen therapy is typically initiated for COPD patients with chronic hypoxemia, usually when SpO₂ is less than 88-90%. An SpO₂ of 92% may not necessarily require oxygen therapy unless the patient is experiencing significant symptoms or has other comorbid conditions.
Correct Answer is C
Explanation
Choice A Reason
“You are not contagious when lesions are healed.” This statement is incorrect. Genital herpes can still be contagious even when there are no visible lesions. The virus can be shed from the skin and transmitted to others even in the absence of symptoms.
Choice B Reason
“This infection is spread through the air.” This statement is incorrect. Genital herpes is not spread through the air. It is primarily transmitted through direct skin-to-skin contact, particularly during sexual activity.
Choice C Reason
“Stress can activate an outbreak.” This statement is correct. Stress is a known trigger for reactivation of the herpes simplex virus, leading to outbreaks of genital herpes. Other triggers can include illness, fatigue, and immune suppression.
Choice D Reason
“Antiviral drugs will cure the infection.” This statement is incorrect. While antiviral drugs can help manage symptoms and reduce the frequency of outbreaks, they do not cure the infection. The herpes simplex virus remains in the body and can reactivate.
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