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.
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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 B
Explanation
A. Intellectual capacity is not affected:
This statement refers to the fact that ALS primarily affects motor neurons, leading to muscle weakness and paralysis, but it typically does not directly impact cognitive function or intellectual capacity. While cognitive impairment is not a hallmark feature of ALS, some individuals may experience changes in cognitive function or behavior, such as executive dysfunction or frontotemporal dementia, in later stages of the disease. However, depression in ALS is not primarily linked to changes in intellectual capacity but rather to other factors such as altered communication, physical limitations, and loss of autonomy.
B. Communication is altered:
ALS can affect the muscles involved in speech and swallowing, leading to difficulties in communicationAs the disease progresses, patients may experience dysarthria (difficulty speaking clearly) and dysphagia (difficulty swallowing), which can impair their ability to communicate effectively with others. Altered communication can result in frustration, social isolation, and feelings of being misunderstood, all of which are risk factors for depression.
C. Mobility is limited:
ALS causes progressive muscle weakness and paralysis, which can significantly impair mobility over time. As the disease advances, individuals with ALS may become increasingly dependent on mobility aids such as wheelchairs or may require assistance with mobility tasks. Limited mobility can lead to feelings of loss of independence, decreased participation in activities, and increased dependence on caregivers, all of which can contribute to depression.
D. Nutritional intake is poor:
ALS can affect the muscles involved in swallowing and chewing, leading to difficulties with eating and drinking. Dysphagia, or difficulty swallowing, is a common symptom in ALS and can result in poor nutritional intake and weight loss. Malnutrition and weight loss are associated with increased morbidity and mortality in ALS, and they can also contribute to feelings of weakness, fatigue, and overall decline in quality of life, which may exacerbate depression.
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