In the context of an initial assessment for a client admitted to rule out Guillain-Barre syndrome, which of the following symptoms would the nurse expect to observe?
Ascending muscle weakness
Difficulty with urination
Ptosis and diplopia
Ear distortion and pain
The Correct Answer is A
Choice A rationale
Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.
Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale
It is a common misconception that something should be placed in the mouth of someone having a seizure to prevent them from biting their tongue. However, this can cause more harm than good, including injury to the person’s mouth or the rescuer’s fingers.
Choice B rationale
Moving furniture away from the person having a seizure can help prevent injury. During a seizure, a person may move uncontrollably, and removing nearby objects can reduce the risk of harm.
Choice C rationale
Loosening constrictive clothing can help the person breathe more easily during and after a seizure.
Choice D rationale
Providing privacy can help maintain the person’s dignity and reduce embarrassment after a seizure.
Choice E rationale
It is not recommended to restrain a person during a seizure. This can result in injury. Instead, the goal is to keep the person safe until the seizure stops on its own.
Choice F rationale
Positioning the person on their side with their head flexed forward can help prevent aspiration, which can occur if the person vomits during or after a seizure.
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