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
A. A heart rate of 56/min indicates bradycardia, which can reduce cardiac output and lead to dizziness due to decreased cerebral perfusion.
B. A high temperature is not directly associated with bradycardia; fever typically causes tachycardia.
C. Hypoglycemia does not have a direct relationship with bradycardia; it is more commonly associated with symptoms like sweating, confusion, and tremors.
D. Cigarette smoking typically contributes to conditions like tachycardia and vascular constriction, not bradycardia.
Correct Answer is C
Explanation
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.