While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?
Profuse sweating.
Weakness in the lower legs.
Loss of sensation at T-8.
Leg pain that worsens at night.
The Correct Answer is C
Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Double vision.Double vision, or diplopia, can indicatephenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen
.The other options do not require immediate intervention:
- A. Chronic insomniais not a critical side effect of phenytoin and may be managed with lifestyle modifications or further assessment.
- B. Puffy, bleeding gumsare common side effects associated with phenytoin (gingival hyperplasia) but are not immediately life-threatening.
- D. Blood pressure 100/78 mm Hgis within normal limits and does not indicate a need for urgent action
Correct Answer is C
Explanation
Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice B rationale
Potatoes and low-fat breads can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice C rationale
Oatmeal, raisins, and fruit with skin are high in fiber, which promotes gut health and is beneficial for colorectal cancer prevention. A nutritious regular diet can improve your gut health, which is a main contributor to colon and rectal health.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
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