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 D
Explanation
A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.
Correct Answer is D
Explanation
A. While hyperlipidemia can contribute to vascular damage, it primarily increases the risk of cardiovascular disease and stroke, rather than directly blocking neuron communication to cause dementia.
B. Peptic ulcer disease is not associated with dementia, and the loss of nerve cells in the stomach does not lead to cognitive decline.
C. Peptic ulcer disease does not cause dementia by impacting neuron communication in the stomach.
D. Vascular dementia is often caused by stroke due to reduced blood flow or damage to the blood vessels in the brain, leading to cognitive decline and memory loss.