A nurse is collecting data from a client who has a possible medical diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?
"Have you traveled overseas recently?"
"Have you had a recent upper respiratory infection?"
"Are you taking a multivitamin?"
"Have you had an MMR immunization?"
The Correct Answer is B
A. While travel can expose individuals to various pathogens, Guillain-Barré syndrome (GBS) is more commonly linked to recent infections rather than overseas travel.
B. GBS is often preceded by an acute viral or bacterial infection, particularly an upper respiratory or gastrointestinal infection. This makes it essential for the nurse to inquire about a recent upper respiratory infection.
C. Taking multivitamins does not have a direct connection to the development of GBS.
D. While some vaccines are associated with GBS, the MMR vaccine is not typically a cause of concern in this context.
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Correct Answer is A
Explanation
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B. Using oral contraceptives can actually increase the risk of stroke, especially in women who smoke or have other risk factors.
C. Maintaining a normal blood pressure is essential; elevated blood pressure can lead to increased risk of stroke, not good blood flow.
D. While moderate alcohol consumption may have some benefits, the general recommendation is to limit intake to reduce stroke risk; therefore, stating that up to 3 drinks a day is safe is misleading.
Correct Answer is A
Explanation
A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), which confirms the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease and is not a relevant finding in myasthenia gravis or the Tensilon test.
C. The Tensilon test assesses muscle strength rather than electrical charge in the muscle; therefore, an increase in electrical activity is not a relevant measure for this test.
D. No change in muscle strength indicates a negative result for myasthenia gravis, suggesting that the test did not confirm the diagnosis.