A patient diagnosed with Guillain-Barré syndrome (GBS) asks how the disease developed since the patient rarely has an illness. What nursing response is the most accurate?
a. "No one knows what causes it."
b. "It may be an autoimmune reaction to a virus."
c. "It most often occurs as a result of a bacterial infection."
d. "It is usually hereditary. Does anyone in your family have it?"
ANS: B
GBS is believed to be caused by an autoimmune response to some type of viral infection or vaccination. A. No one does have an exact cause however this statement is not the most accurate. C. It is believed to occur after a viral infection. D. It is not hereditary.
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A wound with drainage and foul odor should be cleansed with
A. Normal saline B. Hydrogen peroxide C. 20% acetic acid D. Betadine
Which technique should the nurse use to culture wound drainage?
1. Obtain skin and wound exudate. 2. Rotate swab at deep point in wound. 3. Use older secretions for the specimen. 4. Swab back and forth across the wound.
The client who has been taking high-dose corticosteroid therapy for a month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking the corticosteroids. What is the nurse's best response?
A. "It is possible for the inflammation to recur when corticosteroid therapy is halted." B. "Corticosteroids are a type of hormone. Once you have been started on a re-placement hormone, you must continue the hormone replacement therapy for the rest of your life." C. "The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate se-cretion again." D. "The drug suppressed your immune system while you were taking it. Slowly de-creasing the dose over time prevents your immune system from starting up too quickly and initiating allergic reactions."
After insertion of a chest tube for a pneumothorax, a patient becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred
For what cause of tension pneumothorax should the nurse check? A) Infection of the lung B) Kinked or obstructed chest tube C) Excessive water in the water-seal chamber D) Excessive chest tube drainage