A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?
"Have you had an MMR immunization?"
"Have you had a recent upper respiratory infection?"
"Have you traveled overseas recently?"
"Are you taking a multivitamin?"
The Correct Answer is B
A. "Have you had an MMR immunization?"
This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.
B. "Have you had a recent upper respiratory infection?"
This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.
C. "Have you traveled overseas recently?"
While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.
D. "Are you taking a multivitamin?"
The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decreased pedal pulses:
Decreased pedal pulses are not typically associated with increased intracranial pressure. Instead, they may indicate peripheral vascular disease or reduced perfusion to the lower extremities. Monitoring peripheral pulses is important for assessing circulation but is not directly related to intracranial pressure changes.
B. Hypertension:
Hypertension can be a manifestation of increased intracranial pressure. The body may respond to elevated intracranial pressure by increasing blood pressure to maintain cerebral perfusion pressure. However, hypertension alone is not specific to increased ICP and can have various causes.
C. Peripheral edema:
Peripheral edema is not a typical manifestation of increased intracranial pressure. It may occur in conditions such as heart failure or renal dysfunction but is not directly related to intracranial pressure changes following a craniotomy.
D. Diarrhea:
Diarrhea is not a common manifestation of increased intracranial pressure. Increased ICP is more likely to manifest with symptoms such as headache, nausea, vomiting, altered level of consciousness, and focal neurological deficits.
Correct Answer is A
Explanation
A. Bradycardia, hypertension, and widening pulse pressure
This combination of symptoms is characteristic of Cushing's triad. Bradycardia (slow heart rate), hypertension (elevated blood pressure), and widening pulse pressure (difference between systolic and diastolic blood pressure) are indicative of increased ICP, specifically resulting in the compression of brain structures that regulate vital functions.
B. Widening pulse pressure, headache, and seizure
While headache and seizure may occur in patients with increased ICP, widening pulse pressure alone is not sufficient to meet the criteria of Cushing's triad. The presence of bradycardia and hypertension, along with widening pulse pressure, is more indicative of Cushing's triad.
C. Hypertension, tachycardia, and headache
Hypertension and headache may occur in patients with increased ICP, but the absence of bradycardia and widening pulse pressure makes this option less characteristic of Cushing's triad.
D. Hypotension, tachycardia, and narrowing pulse pressure
Hypotension (low blood pressure) and narrowing pulse pressure are not typically associated with Cushing's triad. Tachycardia (rapid heart rate) may occur in response to increased ICP, but it is usually accompanied by bradycardia rather than hypotension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today