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?"

Answer and Explanation

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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Correct Answer is B

Explanation

A. Fresh fish

Fresh fish does not contain significant amounts of tyramine. Therefore, there is no need to eliminate fresh fish from the client's diet due to its interaction with selegiline.

B. Cheddar cheese

This is the correct answer. Cheddar cheese is a high-tyramine food and should be eliminated from the client's diet when taking MAOIs. Aged cheeses, such as cheddar, contain high levels of tyramine due to the fermentation process, which can increase the risk of a hypertensive crisis when combined with MAOIs.

C. Cherries

Cherries do not contain significant amounts of tyramine. Therefore, there is no need to eliminate cherries from the client's diet due to their interaction with selegiline.

D. Chicken

Chicken does not contain significant amounts of tyramine. Therefore, there is no need to eliminate chicken from the client's diet due to its interaction with selegiline.

A. "It is too early to tell. When the spinal shock subsides, we will know more." B. "You should talk to your physician about things of that nature." C. "No. Significant recovery of function should occur in a few days." D. "Yes. In all likelihood, the paralysis is probably permanent."

Correct Answer is A

Explanation

A. "It is too early to tell. When the spinal shock subsides, we will know more."

This response is appropriate. Spinal shock can initially obscure the extent of neurological injury, and it may take time for the full extent of the injury to become apparent. By acknowledging this and suggesting that more information will be available once spinal shock subsides, the nurse provides a realistic perspective without prematurely predicting the outcome.

B. "You should talk to your physician about things of that nature."

This response may come across as dismissive or evasive. While it is true that the physician ultimately determines the patient's prognosis, the family may be seeking reassurance and guidance from the nurse as well.

C. "No. Significant recovery of function should occur in a few days."

This response is overly optimistic and potentially misleading. While some improvement may occur in the days following a spinal cord injury, significant recovery of function within a few days is unlikely, especially in cases of flaccid paralysis of all extremities.

D. "Yes. In all likelihood, the paralysis is probably permanent."

This response is overly pessimistic and lacks sensitivity. It may unnecessarily distress the family and extinguish hope for the patient's recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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