The nurse is caring for a patient with a new diagnosis of Guillian-Barré syndrome. What does the nurse expect to find when assessing this patient?
Increased muscle weakness
Pronounced muscle atrophy
Diminished visual acuity
Impaired cognitive reasoning
The Correct Answer is A
A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.
B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.
C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.
D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings
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Correct Answer is A
Explanation
A) "Women should be familiar with their own breasts so that they can report any changes to their provider": This statement aligns with current recommendations emphasizing the importance of breast self-awareness. Women are encouraged to be familiar with their breast tissue so they can recognize any changes, such as lumps or alterations in size or shape, and report these changes to their healthcare provider. This proactive approach can lead to earlier detection of breast cancer.
B) "All women should have a breast screening with an MRI beginning at age 40": This statement is misleading, as the American Cancer Society does not recommend routine MRI screenings for all women. MRI is typically reserved for women at high risk for breast cancer. The standard guideline includes annual mammograms starting at age 40, but not MRI for all.
C) "Mammograms do not help with detecting breast cancer until after age 54": This statement is incorrect. Mammograms are effective in detecting breast cancer well before age 54, and the American Cancer Society recommends that women start getting annual mammograms at age 40. Early detection through regular screenings is critical for improving outcomes.
D) "Mammograms are only indicated if there is a strong family history": This statement is also inaccurate. While family history can increase the risk for breast cancer and may influence screening frequency, all women are encouraged to have regular mammograms starting at age 40, regardless of family history. This guideline aims to catch potential cancers early in all women.
Correct Answer is ["A","C","D"]
Explanation
A) Texture: Assessing the texture of the skin is an important part of a comprehensive skin assessment. It provides insights into the health and hydration status of the skin. Normal skin texture should feel smooth and even, while changes can indicate issues such as dryness or conditions like eczema or psoriasis.
B) Tachypnea: This term refers to an increased respiratory rate and is not a characteristic assessed in the skin. While it can indicate a physiological response to various conditions, it does not relate to skin health or characteristics and therefore is not relevant in this context.
C) Turgor: Skin turgor refers to the elasticity and hydration status of the skin, which can be assessed by pinching the skin. Proper turgor indicates adequate hydration, while decreased turgor can signal dehydration or other health issues. This is an essential component of skin assessment.
D) Temperature: Assessing the temperature of the skin can provide information about circulation and potential inflammation or infection. Normal skin temperature should feel warm and consistent, while variations can suggest underlying conditions such as fever or shock.
E) Tympany: Tympany is a term used in percussion assessments of the abdomen and is not applicable to skin assessment. It refers to a hollow sound produced by tapping on a body surface and does not pertain to skin characteristics.