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?

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Question 1 of 5

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: Guillain-Barre Syndrome (GBS) is an autoimmune disorder where the body's immune system mistakenly attacks the peripheral nerves. This leads to inflammation that damages the nerves and interrupts their ability to send signals to the brain. In the case of the 32-year-old male patient with weak legs, the autoimmune reaction is most likely responsible for causing muscle weakness and difficulty walking. GBS typically presents with ascending muscle weakness starting in the legs and progressing upwards. It is essential to recognize this condition promptly as it can lead to severe complications such as respiratory failure. Treatment often involves supportive care and interventions to manage the autoimmune response.

Question 2 of 5

The client with trigeminal neuralgia tells the nurse that acetaminophen (Tylenol) is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

Correct Answer: B

Rationale: Acetaminophen toxicity can lead to hepatic injury, resulting in elevated liver enzymes, including bilirubin levels. Direct bilirubin is a specific marker for liver function and is typically elevated in cases of acetaminophen overdose or toxicity. Therefore, a direct bilirubin level of 2 mg/dl would indicate toxicity associated with acetaminophen use. Monitoring liver function tests, including bilirubin levels, is crucial when using acetaminophen long-term to prevent toxicity and liver damage.

Question 3 of 5

The ff are the tonometer measurements of five clients. Which of them has normal intraocular pressure (IOP)? Choose all that apply

Correct Answer: C

Rationale: Normal intraocular pressure (IOP) typically ranges between 10 and 21 mm Hg. For this reason, the tonometer measurements of 11 mm Hg and 20 mm Hg fall within the normal range. Therefore, clients with these IOP values (Option C and E) have normal intraocular pressure. The other options (A, B, and D) are outside the normal range for IOP and are therefore considered elevated.

Question 4 of 5

Which of the following types of hearing loss does the nurse understand is most improved with the use of a hearing aid?

Correct Answer: C

Rationale: Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or the auditory nerve. This type of hearing loss is most commonly associated with aging or prolonged exposure to loud noises. Sensorineural hearing loss is typically permanent and cannot be medically or surgically corrected; however, it can be effectively managed with hearing aids. A hearing aid can amplify sound and help individuals with sensorineural hearing loss improve their ability to hear and communicate effectively. Conductive and mixed hearing losses may benefit from other interventions such as surgical procedures, while central hearing loss is related to the processing of sound in the brain and is not effectively managed by hearing aids.

Question 5 of 5

A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg PO daily. Which finding should the nurse recognize as an adverse effect?

Correct Answer: B

Rationale: Levothyroxine is a synthetic form of thyroid hormone used to treat hypothyroidism. An adverse effect of levothyroxine therapy is the development of tachycardia, which is an abnormally rapid heart rate. This is due to the increased metabolic rate resulting from the thyroid hormone replacement. Dysuria (painful urination), leg cramps, and blurred vision are not typically associated with levothyroxine therapy for hypothyroidism.

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