A 32 y.o. male patient is admitted to a medical unit with a diagnosis of Guillain-Barre Syndrome. His legs are weak, and he is unable to walk without assistance. Which of the ff. is most likely responsible for this syndrome?

Correct Answer: D

Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Correct Answer: D

Rationale: The correct answer is D: absence seizures. Barbiturate anticonvulsants are not effective in treating absence seizures because they can worsen this type of seizure by suppressing brain activity. Barbiturates are typically used to treat tonic-clonic seizures and partial seizures, but not absence seizures. Febrile seizures are typically managed without barbiturate anticonvulsants. In summary, barbiturate anticonvulsants are effective in treating partial seizures and tonic-clonic seizures, but not absence seizures or febrile seizures due to their mechanisms of action and potential side effects.

Correct Answer: D

Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.

Correct Answer: B

Rationale: The correct answer is B: Blurring of vision. This is typically the first symptom of a cataract because the clouding of the lens causes light to scatter, leading to blurred vision. Dry eyes (A) and eye pain (C) are not typically associated with cataracts. Loss of peripheral vision (D) is more commonly seen in conditions like glaucoma. In summary, blurring of vision is the hallmark symptom of cataracts due to lens clouding, distinguishing it from other eye conditions.

Correct Answer: D

Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.