Which is a common verbalization of the patient with GBS regarding the EARLY ONSET of symptoms?

Correct Answer: B

Rationale: Guillain-Barré Syndrome (GBS) is characterized by ascending motor weakness, starting typically in the lower extremities and progressing upwards. Patients with GBS often verbalize the early onset of symptoms as weakness starting in the legs and potentially spreading to involve the arms and sometimes the face. Therefore, the common verbalization of the patient with GBS regarding the early onset of symptoms is ascending motor weakness. Acute hemiplegia (choice A) and acute hemiparesis (choice D) involve weakness or paralysis typically limited to one side of the body, which is not a characteristic presentation of GBS. Weakness of the four lower extremities (choice C) is also not a typical description in GBS as the weakness usually starts distally and progresses proximally.

Correct Answer: A

Rationale: The presentation described in the question is most consistent with anterior uveitis. Anterior uveitis, also known as iritis, is characterized by redness, pain, and photophobia in the affected eye. Slit-lamp examination typically reveals ciliary injection (reddening of the conjunctiva and episclera), corneal edema, and a mid-dilated pupil with a fixed reaction to light (miosis). This occurs due to inflammation within the anterior chamber of the eye involving the iris and ciliary body.

Correct Answer: B

Rationale: Option B is the most appropriate response when addressing a postpartum client's concerns about resuming sexual activity after a vaginal delivery. Educating the client about the normal changes in sexual desire and response following childbirth can help alleviate anxiety and provide reassurance. It is crucial for the nurse to explain that it is common for women to experience changes in libido, physical discomfort, and emotional adjustments after giving birth. By discussing these normal postpartum changes, the nurse can support the client in understanding that her feelings are valid and that it may take time for her to feel ready to engage in sexual activity again. Furthermore, the nurse can provide information on ways to enhance comfort and intimacy when resuming sexual activity, such as communication with partners, using lubricants, and gradually easing back into sexual activity as desired.

Correct Answer: A

Rationale: Rhinitis is inflammation of the nasal mucosa, and common clinical manifestations include nasal congestion (blockage or stuffiness), rhinorrhea (runny nose), and sneezing. These symptoms are often present in both allergic and non-allergic rhinitis. While headaches, sore throat, and fever can occur in some cases, they are not as specific to rhinitis as nasal congestion, rhinorrhea, and sneezing.

Correct Answer: B

Rationale: It is important for the nurse to have a direct and easily accessible means of communication with the patient who is expected to be in and out of the hospital due to their chronic illness like leukemia. By asking for the patient's phone number, the nurse can quickly reach out to them for updates, clarification, or any urgent matters that may arise. This direct communication line helps in ensuring continuity of care and addressing the patient's needs promptly. This approach is more practical and efficient compared to options such as asking the patient to call the hospital number listed in the yellow pages or relying on chart information which may not always be up to date. Writing down the number and giving it to the ward clerk may cause unnecessary delays in communication.

Correct Answer: C

Rationale: Collaborating with interdisciplinary team members to develop a comprehensive care plan demonstrates effective care coordination. In complex healthcare situations, involving various healthcare providers such as physicians, specialists, therapists, social workers, and others is crucial to ensure that all aspects of the patient's care are addressed holistically. By working together, healthcare professionals can share information, expertise, and insights to develop a well-rounded care plan that considers all aspects of the patient's needs. This collaborative approach helps promote better outcomes for the patient and enhances overall care coordination. It also helps to ensure that the patient's preferences and values are taken into account when developing the care plan.

Correct Answer: D

Rationale: The symptoms described by the patient indicate a potential transfusion reaction, such as a hemolytic reaction or allergic reaction. The immediate action the nurse should take in such a situation is to stop the infusion of the packed red blood cells. This will help prevent further complications and ensure the safety of the patient. After stopping the infusion, the nurse should assess the patient's condition, monitor vital signs, and inform the healthcare team, including the physician, regarding the situation. Once the patient is stable, further investigations can be conducted to determine the cause of the reaction.

Correct Answer: A

Rationale: When a patient is in a somnolent status and still under the effect of anesthesia, the most appropriate position to place the patient is in a supine position with the head of the bed slightly elevated. This position helps prevent any obstruction of the airway and promotes optimal ventilation. Elevating the head of the bed ensures that the patient's airway remains clear and allows for proper breathing. Additionally, this position helps prevent aspiration and promotes proper circulation. Overall, the supine position with the head bed slightly elevated is the safest and most effective position for a patient in this condition.

Correct Answer: A

Rationale: Magnetic Resonance Imaging (MRI) is a specialized medical imaging technique that uses magnetic fields and radio waves to create detailed images of the organs and tissues within the body. In the context of the scenario provided, an MRI is ordered by the attending physician to validate the medical impression.