The client recently diagnosed with Guillain-Barre' syndrome is drooling and having difficulty swallowing secretions. When asked why this is happening, which of the following is the best answer for the nurse to give to the family?
The disorder causes enlargement of parotid and salivary glands
It is caused by obstructed blood flow to the brain
The client has a deficiency of thiamine and pyridoxine in the central nervous system
Cranial nerves responsible for the swallow and the gag reflex have been affected by demyelination caused by the disorder
The Correct Answer is D
Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.
Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.
Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.
Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
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