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 B
Explanation
A) Dietary history from the patient: This information is subjective as it relies on the patient’s personal account of their eating habits, which may be influenced by memory or perception. It does not provide measurable data.
B) BMI (Body Mass Index): This is an objective measure calculated from a person’s height and weight. It provides quantifiable data that can be used to assess nutritional status and potential health risks associated with body weight.
C) Patient history of alcohol intake: This information is subjective as it is based on the patient’s self-report. It does not provide direct evidence and may vary depending on how the patient perceives their alcohol consumption.
D) Patient complaint of weight loss: This is also subjective data, as it relies on the patient’s perception of their weight change. It does not provide concrete measurements and can be influenced by various factors such as mood or misunderstanding of the situation.
Correct Answer is A
Explanation
A) No discomfort: When palpating the sinuses, the expected finding is that there should be no discomfort. Healthy sinuses typically do not cause pain or tenderness during palpation, indicating that they are clear and not inflamed or infected.
B) Lumps less than 1 centimeter: While lumps may be found in various areas of the body, the presence of lumps in the sinus area during palpation is not a typical finding and may indicate an abnormality or concern that would require further evaluation.
C) Painful sensation behind the eyes: A painful sensation behind the eyes can indicate sinusitis or other sinus issues. It is not an expected finding during a normal examination of the sinuses, as healthy sinuses should not cause discomfort.
D) Heavy pressure: Heavy pressure is often a symptom associated with sinusitis or sinus congestion, but it is not an expected finding during a routine palpation of the sinuses. Healthy sinuses should not feel heavy or pressured during examination.