Guillain-Barré Syndrome NCLEX Review

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff? 1. Provide an erase slate board for the client to write on .2. Instruct the client to blink once for "no" and twice for "yes." 3. Refer to a speech therapist to help with communication. 4. Leave the call light within easy reach of the client.

2 The client will not be able to use the arms as a result of the paralysis but can blink the eyes as long as the nurse asks simple "yes-or-no" questions. 1.The ascending paralysis has reached the client's respiratory muscles; therefore, the client will not be able to use the hands to write. 3. A speech therapist will not be able to help the client communicate while the client is on the ventilator. 4. The ascending paralysis has reached the respiratory muscles; therefore, the client will not be able to use the hands to push the call light

The client diagnosed with Guillain-Barré syndrome is on a ventilator. When the wife comes to visit she starts crying uncontrollably, and the client starts fighting the ventilator because his wife is upset. Which action should the nurse implement? 1. Tell the wife she must stop crying. 2. Escort the wife out of the room. 3. Medicate the client immediately. 4. Acknowledge the wife's fears.

4 It is scary for a wife to see her loved one with a tube down his mouth and all the machines around them. The nurse should help the wife by acknowledging her fears 1. This action does not address the wife's fears, and telling her to stop crying will not help the situation. 2. Making the wife leave the room will further upset the client and the client's wife. 3. Medicating the client will not help the wife, but if the nurse can calm the wife,then it is hoped the client will calm down.

The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which pre procedure intervention has priority? 1. Keep the client NPO. 2. Instruct the client to void. 3. Place in the lithotomy position. 4. Assess the client's pedal pulse.

2. The client should void prior to this procedure to help prevent accidental puncture of the bladder during the procedure. 1. The client does not need to be NPO prior to this procedure. 3. The lithotomy position has the client lying flat with the legs in stirrups, such as when Pap smears are obtained. 4. The pedal pulses should be assessed postprocedure, not prior to the procedure.

The client diagnosed with Guillain-Barré syndrome asks the nurse, "Will I ever get back to normal?I am so tired of being sick." Which statement is the best response by the nurse? 1. "You should make a full recovery within a few months to a year." 2. "Most clients with this syndrome have some type of residual disability." 3. "This is something you should discuss with the health-care team." 4. "The rehabilitation is short and you should be fully recovered within a month."

1 Clients with this syndrome usuallyhave a full recovery, but it may take upto one (1) year. 2. Only about 10% of clients are left with permanent residual disability. 3. This is "passing the buck." The nurse should answer the client's question honestly, which helps establish a trusting nurse-client relationship. 4. This indicates the nurse does not under-stand the typical course for a client diagnosed with Guillain-Barré syndrome.

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome? 1. Assess deep tendon reflexes. 2. Complete a Glasgow Coma Scale. 3. Check for Babinski's reflex. 4. Take the client's vital signs.

1 Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. Therefore, assessing deep tendon reflexes is appropriate. 2. A Glasgow Coma Scale is used for clients with potential neurological deficits and used to monitor for increased intracranial pressure. 3. Babinski's reflex evaluates central nervous system neurological status, which is not affected with this syndrome. 4. Vital signs are a part of any admission assessment but are not a specific assessment intervention for this syndrome

The client diagnosed with Guillain-Barré syndrome is admitted to the rehabilitation unit after 23 days in the acute care hospital. Which interventions should the nurse implement?Select all that apply. 1. Refer client to the physical therapist. 2. Include the speech therapist in the team. 3. Request a social worker consult. 4. Implement a regimen to address pain control. 5. Refer the client to the Guillain-Barré Syndrome Foundation

1, 3, 4, 5 1.The physical therapist is an important part of the rehabilitation team who addresses the client's muscle deterioration resulting from the disease process and immobility. 3.The social worker could help with financial concerns, job issues, and issues concerning the long rehabilitation time for this syndrome. 4.Pain may or may not be an issue with this syndrome. Each client is different,but a plan needs to be established to address pain if it occurs. 5.This is an excellent resource for the client and the family 2. There is no residual speech deficit fromGuillain-Barré syndrome; therefore, this referral is not appropriate.

The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem "impaired physical mobility." Which long-term goal should be written for this problem? 1. The client will have no skin irritation. 2. The client will have no muscle atrophy. 3. The client will perform range-of-motion exercises. 4. The client will turn every two (2) hours while awake.

2 The client with Guillain-Barré syndrome will not be able to move the extremities; therefore, preventingmuscle atrophy is an appropriate long-term goal 1. This is an appropriate long-term goal for the client problem "impaired skin integrity." 3. The client will not be able to move the extremities. Therefore, the nurse will have to do passive range-of-motion exercises;this is an intervention, not a goal. 4. This is a nursing intervention, not a goal,and the client should be turned while sleeping unless the client is on a special immobility bed

Which statement by the client supports the diagnosis of Guillain-Barré syndrome? 1. "I just returned from a short trip to Japan." 2. "I had a really bad cold just a few weeks ago." 3. "I think one of the people I work with had this." 4. "I have been taking some herbs for more than a year."

2 This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks prior to the onset of neurological deficits. 1. Visiting a foreign country is not a risk factor for contracting this syndrome. 3. This syndrome is not a contagious or a communicable disease. 4. Taking herbs is not a risk factor for developing Guillain-Barré syndrome

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse? 1. The ventilator rate is set at 14 breaths per minute. 2. A manual resuscitation bag is at the client's bedside. 3. The client's pulse oximeter reading is 85%. 4. The ABG results are pH 7.40, PaO288, PaCO235, and HCO324.

3 A pulse oximeter reading of less than 93% warrants immediate intervention;a 90% peripheral oxygen saturation indicates a PaO2 of about 60 (normal,80 to 100). When the client is placed on the ventilator, this should cause the client's oxygen level to improve. 1. The rate of ventilation is usually 12 to 15 breaths per minute in adults who are on ventilators, so this rate does not require immediate intervention. 2. A manual resuscitation (Ambu) bag must be at the client's bedside in case the ventilator malfunctions; the nurse must bag the client. 4. These ABGs are within normal limits and do not warrant immediate intervention

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? 1. An exaggerated startle reflex and memory changes. 2. Cogwheel rigidity and inability to initiate voluntary movement. 3. Sudden severe unilateral facial pain and inability to chew. 4. Progressive ascending paralysis of the lower extremities and numbness.

4 Ascending paralysis is the classic symptom of Guillain-Barré syndrome 1. These signs/symptoms, along with sleep disturbances and nervousness, support the diagnosis of Creutzfeldt-Jakob disease. 2. These signs/symptoms support the diagnosis of Parkinson's disease. 3. These are signs/symptoms of trigeminal neuralgia.

The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement post procedure? 1. Monitor the client for hypotension. 2. Apply pressure to the puncture site. . Test the client's cerebrospinal fluid. 4. Increase the client's fluid intake.

4 Increased fluid intake will help prevent a postprocedure headache, which may occur after a lumbar puncture. 1. Very little cerebrospinal fluid is removed the client. Therefore, hypotension is not a potential complication of this procedure. 2. A bandage is placed over the puncture site,and pressure does not need to be applied to the site. 3. The laboratory staff, not the nurse, complete tests on the cerebrospinal fluid; the nurse could label the specimens and take them to the laboratory

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome? 1. High risk for injury. 2. Fear and anxiety. 3. Altered nutrition. 4. Ineffective breathing pattern.

4 Guillain-Barré syndrome has ascendingparalysis causing respiratory failure.Therefore, breathing pattern is priority. 1. Safety is an important issue for the client,but this is not the priority client problem. 2. The client's psychological needs are important, but psychosocial problems are not priority over physiological problems. 3. Clients with this syndrome may have choking episodes and are at risk for inability to swallow as a result of the disease process, but this is not the priority nursing problem because weight loss is not an expected complication of this syndrome.