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) Lordosis: This term specifically refers to an exaggerated inward curvature of the spine, particularly in the cervical or lumbar regions. When the nurse observes an exaggerated cervical curve, lordosis is the correct term to use for documentation, indicating a deviation from the normal spinal alignment.
B) Scoliosis: This condition is characterized by an abnormal lateral curvature of the spine. It does not apply to the observation of an exaggerated cervical curve and would not be appropriate for this finding.
C) Kyphosis: This term denotes an excessive outward curvature of the thoracic spine, often leading to a hunchback appearance. Since the assessment focuses on the cervical region, kyphosis would not accurately describe an exaggerated cervical curve.
D) Normal curve: This term refers to the expected, healthy curvature of the spine. Documenting an exaggerated curve as "normal" would be misleading and does not accurately reflect the observed condition. The nurse should document the finding as lordosis to convey the specific abnormality noted.
Correct Answer is A
Explanation
A) Subjective report: The most reliable indicator of pain is the patient's own description of their experience. Pain is inherently subjective, and individuals may perceive and express pain differently. Listening to the client's self-report provides valuable insight into their pain intensity, quality, and impact on daily life, which cannot be accurately assessed through objective measures alone.
B) Physical exam: While a physical exam can provide important information about potential sources of pain or related conditions, it may not accurately reflect the intensity or nature of the pain the patient is experiencing. Physical findings may vary widely among individuals with similar pain complaints, making this a less reliable indicator.
C) Results of a CAT scan: Imaging studies like CAT scans can identify structural issues, such as fractures or tumors, but they do not measure pain. Many patients with significant pain may have normal imaging results, while others with severe findings may report minimal discomfort, underscoring the limitations of relying solely on diagnostic tests.
D) The client's vital signs: Vital signs can indicate physiological responses to pain, such as increased heart rate or blood pressure, but they are not specific indicators of pain severity. Many factors can influence vital signs, including anxiety and other medical conditions, making them unreliable for assessing pain levels independently.