A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...

intubation and mechanical ventilation.

IV infusion of (Sandoglobulin).

administration of methylprednisolone (Solu-Medrol).

insertion of a nasogastric (NG) feeding tube

Answer and Explanation

The Correct Answer is B

Choice A rationale: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.

Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.

Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.

Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.

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Correct Answer is D

Explanation

Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.

Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.

Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.

Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.

A. Perform active range of motion three times daily. B. Maintain the head of bed in a flat or 30 degree position. C. Teach measures to avoid the Valsalva maneuver. D. Monitor for Battle's sign every four hours.

Correct Answer is C

Explanation

Choice A rationale: Performing active range of motion exercises may not be safe or appropriate immediately following a hemorrhagic stroke.

Choice B rationale: Maintaining the head of bed flat or at a 30-degree position might be used for ischemic strokes but not necessarily for hemorrhagic strokes.

Choice C rationale: Teaching measures to avoid the Valsalva maneuver (straining during activities like defecation) helps prevent sudden increases in intracranial pressure, which can be detrimental after a hemorrhagic stroke.

Choice D rationale: Monitoring for Battle's sign (bruising behind the ears associated with basilar skull fracture) is not relevant in the care of a hemorrhagic stroke.

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A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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