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 C
Explanation
A. Decreasing activity is not recommended for peripheral venous disease; clients are encouraged to engage in physical activity to promote circulation and prevent complications.
B. Massaging legs may not be advisable as it could exacerbate swelling and discomfort; instead, elevation is often recommended.
C. Inspecting legs daily for changes is essential for early detection of complications such as skin changes or ulcers, indicating the client understands the importance of monitoring their condition.
D. Keeping legs in a dependent position can worsen venous pooling and swelling; elevation is generally recommended to improve venous return.
Correct Answer is D
Explanation
A. Applying ice to the extremity is generally not recommended for DVT due to the risk of promoting vasoconstriction and worsening the condition; warm compresses are usually indicated instead.
B. There is no need to restrict oral fluids for a client with DVT unless there are other specific medical reasons; hydration is important.
C. Vasodilating medications are not standard treatment for DVT and may not be appropriate; anticoagulants are typically the primary treatment.
D. Monitoring platelet levels is important in managing DVT, especially when anticoagulants are used, to assess for potential complications such as heparin-induced thrombocytopenia (HIT), making this option correct.