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 ["42"]
Explanation
Step 1: Convert the volume from liters to milliliters. 1 liter = 1000 mL. Step 2: Convert the time from hours to minutes. 4 hours = 240 minutes.
Step 3: Calculate the rate in mL per minute. Rate = Volume ÷ Time = 1000 mL ÷ 240 min = 4.17 mL/min.
Step 4: Calculate the drops per minute. Drops per minute = Rate × Drop factor = 4.17 mL/min
× 10 gtt/mL = 41.7 gtt/min.
Step 5: Round off the result to the nearest whole number. 41.7 gtt/min rounds off to 42 gtt/min.
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
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