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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A lumbar puncture is a key diagnostic procedure for suspected bacterial meningitis. It allows for the collection of cerebrospinal fluid, which can be analyzed for signs of bacterial infection.
Choice B rationale
Skull radiography is not typically used to diagnose bacterial meningitis. While it can help identify abnormalities in the structure of the skull or brain, it cannot detect the presence of bacteria.
Choice C rationale
While an MRI can provide detailed images of the brain and surrounding tissues, it is not the primary tool for diagnosing bacterial meningitis. It may be used in conjunction with other tests, but a lumbar puncture is more definitive.
Choice D rationale
A CT scan can be used to detect abnormalities in the brain, such as swelling or inflammation, which could be indicative of meningitis. However, it cannot definitively diagnose bacterial meningitis.
Correct Answer is B
Explanation
Choice A rationale
While spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
Drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
Clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
Avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today