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. A QRS interval of 0.08 second is within the normal range and does not indicate a myocardial infarction.
B. A PR interval of 0.15 second is normal and not indicative of an acute myocardial infarction.
C. ST-segment elevation above the isoelectric line is a key indicator of an acute myocardial infarction (STEMI), signifying myocardial injury.
D. The QT interval being equal to the R to R interval is not a specific indicator of myocardial infarction.
Correct Answer is A
Explanation
A. Computerized tomography angiography (CTA) is commonly used to visualize blood vessels and identify any blockages or abnormalities in blood flow that may have contributed to a TIA.
B. While a complete blood count (CBC) may be ordered as part of the general assessment, it is not specific for diagnosing TIA and does not provide information on cerebrovascular issues.
C. A transesophageal echocardiogram (TEE) is used to assess cardiac function and may be indicated in some stroke cases, but it is not the primary diagnostic test for TIA.
D. Prothrombin time (PT) assesses clotting function but is not specific for diagnosing TIA; it may be ordered for other reasons but is not a primary diagnostic tool in this context.