Guillain-Barre

The nurse is caring for a patient with Guillain-Barré syndrome. Assessment findings include: Vital capacity - 4 mL/kg, respiratory rate - 30 breaths per minute, SpO 2 - 88%, rhonchi on lung auscultation and cyanosis. What is the best action for the nurse to take? A. Prepare for endotracheal intubation. B. Administer oxygen via nasal cannula. C. Request a treatment from the respiratory therapist. D. Elevate the head of the bed to at least 45 degrees.

ANS: A

The nurse encourages a ventilated patient with advanced Guillain-Barré syndrome (GBS) to communicate by which simple technique? A. Blinking for "yes" or "no" B. Moving lips to speak C. Using sign language D. Using a laptop to write

ANS: A A simple technique involving eye blinking or moving a finger to indicate "yes" and "no" is the best way for the ventilated patient with GBS to communicate. Moving the lips is difficult to do around an endotracheal tube and is exhausting for the patient. Sign language is very time-consuming to learn, unless the patient and family already know it. Use of a laptop may prove too challenging for the patient in advanced stages of GBS.

12. An older client is hospitalized with Guillain-Barré syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Check the medication list for interactions. c. Place the client on a bed alarm. d. Put the client on safety precautions.

ANS: A In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate, but only after this assessment occurs.

5. The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) a. Ask occupational therapy to help the client with activities of daily living. b. Consult with the provider about a physical therapy consult. c. Provide the client with information on support groups. d. Refer the client to a medical social worker or chaplain. e. Work with speech therapy to design a high-protein diet.

ANS: A, B, E Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do not help with mobility.

A patient is receiving plasmapheresis through a shunt in the right arm for Guillain-Barré syndrome. The nurse should notify the physician of which abnormal finding? A. Dry access site B. Absence of a bruit C. Presence of a thrill D. No bruising at the access site

ANS: B Absence of bruit is an abnormal finding in the nurse's assessment because the plasmapheresis shunt may not be patent. A dry access site is a normal finding when assessing the shunt access site. Presence of a thrill is an expected finding when assessing patency of the shunt. An access site without bruising is a normal finding when assessing the skin at the access site.

The nurse is caring for a patient with Guillain-Barré syndrome (GBS) who is receiving immunoglobulin (IVIG). Which assessment finding warrants immediate evaluation? A. Chills B. Generalized malaise C. Headache with stiff neck D. Temperature of 99° F (37° C)

ANS: C A headache with a stiff neck may be a sign of aseptic meningitis, a possible serious complication of IVIG therapy. Chills, generalized malaise, and a low-grade fever are minor adverse effects of IVIG therapy and do not indicate that the therapy should be stopped.

3. A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? a. Anxiety b. Low fluid volume c. Inadequate airway d. Potential for skin breakdown

ANS: C Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.

Which statement correctly illustrates the commonality between Guillain-Barré syndrome (GBS) and myasthenia gravis (MG)? A. Demyelination of neurons is a cause of both diseases. B. Both diseases are autoimmune diseases with ocular symptoms. C. Both diseases affect the patient's respiratory status and muscle function. D. Both diseases exhibit exacerbations and remissions of their signs and symptoms

ANS: C Both GBS and MG affect respiratory status and muscle function. Only MG is an autoimmune disease with ocular symptoms, and is characterized by exacerbations and remissions, whereas GBS has three acute stages. GBS causes demyelination of the peripheral neurons.

Which are clinical manifestations of Guillain-Barré syndrome? Select all that apply. A. Ptosis B. Fatigue C. Respiratory failure D. Ascending paralysis E.Increased deep tendon reflexes F. Muscle weakness improving with rest

ANS: C,D Clinical manifestations of Guillain-Barré syndrome include respiratory failure and ascending paralysis. Ptosis is a clinical manifestation of myasthenia gravis. Fatigue is a clinical manifestation of myasthenia gravis. Increased deep tendon reflexes are not a clinical manifestation of Guillain-Barré syndrome. Muscle weakness improving with rest is a clinical manifestation of myasthenia gravis.

Which assessment finding is most indicative of Guillain-Barré syndrome (GBS)? A. Pupillary dilation B. Expressive aphasia C. Loss of bowel and bladder control D. A sudden onset of muscle weakness and pain

ANS: D Although features vary, most patients report a sudden onset of muscle weakness and pain. GBS does not affect speech or pupillary dilation. GBS does affect bowel and bladder control and function, but it is not specific to GBS. Sudden-onset muscle weakness and pain are more indicative of GBS.

Which laboratory result is consistent with the diagnosis of Guillain-Barré syndrome (GBS)? A. Positive rheumatoid factor B. Decreased serum albumin C. Decreased erythrocyte sedimentation rate D. Increased protein in the cerebrospinal fluid

ANS: D An increase in the cerebrospinal fluid protein level occurs in GBS due to the release of plasma proteins from inflammation and damage to nerve roots. This release does not affect serum protein levels, which remain normal. The rheumatoid factor is not elevated in this disease and the erythrocyte sedimentation rate could rise.

The patient with Guillain-Barré Syndrome (GBS) is experiencing an inability to smile, frown, and drink from a straw. The nurse knows the GBS has involved which cranial nerve (CN)? A. X B. IX C. XI D. VII

ANS: D CN VII is the facial nerve, which affects the patient's ability to smile, frown, whistle, or drink from a straw. The patient's ability to cough, gag, or swallow is affected by involvement of CNs IX and X. CN XI affects the ability to shrug the shoulders.

A nurse is assessing an adult patient in an inpatient unit. The patient states, "I came into the emergency department because I was experiencing numbness in my feet. On the way to the hospital, it got worse and went up my legs and I couldn't move them." What disease of the peripheral nervous system is the patient experiencing? A. Bell palsy B. Myasthenia gravis C. Restless leg syndrome D. Guillain-Barré syndrome

ANS: D Numbness and paralysis that started in the feet and traveled up the legs is a hallmark sign of ascending paralysis in Guillain-Barré syndrome. Bell palsy is characterized by a drawing sensation and paralysis of all facial muscles on the affected side. Myasthenia gravis is characterized by general weakness. Restless leg syndrome is characterized by leg paresthesias associated with an irresistible urge to move.

A nurse is teaching the family members of a patient who has myasthenia gravis about drug therapy. Which of the family member's statements indicates a need for further teaching? A. "We should plan strenuous activities when the drugs wear off." B. "We should keep the drugs and a glass of water at the bedside." C. "We should set an alarm to remind us when the patient should take the drugs." D. "We should call the health care provider before the patient takes any over-the-counter drugs."

ANS: A Strenuous activities should be planned for when the drugs peak, not wear off. The remaining statements are correct. Drugs and water should be kept at the patient's bedside in case he or she is weak in the morning. The family members and patient should set an alarm to keep the patient from missing doses. Before taking over-the-counter drugs, the patient or family should call the health care provider to ensure it is safe to do so.

Which surgical intervention does the nurse expect to be included in long-term management for symptoms of myasthenia gravis (MG)? A. Thyroidectomy B. Thymectomy C. Pineal gland removal D. Anterior pituitary removal

ANS: B For patients with MG, thymectomy is usually performed early in the course of the disease. Removal of the thyroid gland, the pineal gland, or the anterior pituitary is not indicated and will not improve symptom management.

The nurse caring for a patient with Guillain-Barré syndrome is assessing the functions of the patient's cranial nerves. What cranial nerve deficit may be present if the patient is unable to shrug the shoulders? A. Vagus nerve B. Accessory nerve C. Hypoglossal nerve D. Glossopharyngeal nerve

ANS: B If the patient is unable to shrug the shoulders, the accessory nerve may be damaged. If the patient has glossopharyngeal and vagus nerve deficits, the patient would be unable to cough, gag, or swallow. The patient may be unable to stick the tongue out straight if there is a deficit in the hypoglossal nerve.

A patient is admitted with an exacerbation of Guillain-Barré syndrome (GBS), presenting with dyspnea. Which intervention does the nurse perform first? A. Suctions the patient B. Raises the head of the bed to 45 degrees C. Calls the Rapid Response Team to intubate D. Instructs the patient on how to cough effectively

ANS: B The head of the patient's bed should be raised to 45 degrees because this allows for increased lung expansion, which improves the patient's ability to breathe. Intubation is indicated only if dyspnea is severe or oxygenation saturation does not respond to oxygen therapy. Close monitoring of respiratory status is indicated because of the acute stages of GBS. Instructing the patient on how to cough effectively is not the priority in this case. The patient should be suctioned only if needed to avoid vagal stimulation.

4. An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) a. Administering the medication as ordered b. Advising the client to have help getting up c. Consulting the provider about the drug d. Cutting the dose of the drug in half e. Placing the client on safety precautions

ANS: B, C, E Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate for older clients, cutting the dose in half is not warranted.

1. A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? a. Bladder control b. Cognitive perception c. Respiratory system d. Sensory functions

ANS: C Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

hat other term is used to refer to Guillain-Barré syndrome? A. Cranial polyneuritis B. Trigeminal neuralgia C. Polyradiculoneuropathy D. Eaton-Lambert syndrome

ANS: C Guillain-Barré syndrome is also called polyradiculoneuropathy because it is a polyneuropathy affecting peripheral nerves. Cranial polyneuritis is the term for Bell's palsy. Eaton-Lambert syndrome is a type of myasthenia gravis. Trigeminal neuralgia is a disease affecting the trigeminal nerve or cranial nerve V.

Which statement best describes the pathophysiologic changes associated with Guillain-Barré syndrome (GBS)? A. It is a degenerative disorder that results in bone loss and muscle wasting. B. It is an autoimmune disorder that results in a decrease in the amount of acetylcholine that reaches skeletal muscle. C. It is an immune disorder in which the immune system destroys the myelin sheath of peripheral nerves. D. It is an infectious disorder that results in the bacterial invasion and destruction of skeletal muscle.

ANS: C In GBS, the immune system destroys the myelin sheath, causing demyelination of the nerves leading to weakness and sensory abnormalities. Myasthenia gravis is the autoimmune disorder resulting in decreased acetylcholine. GBS is not an infectious disorder; however, it is often preceded by an infectious illness. Rheumatoid arthritis is the degenerative disease that leads to bone loss and muscle wasting.

2. The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? a. Delayed afferent nerve impulses b. Paralysis of affected muscles c. Paresthesia in upper extremities d. Slowed nerve impulse transmission

ANS: D Demyelination leads to slowed nerve impulse transmission. The other options are not correct.

The nurse reviews a patient's medical record and notes a history of lung carcinoma and a medication history of pyridostigmine. The patient is experiencing weakness of the pelvis and shoulder. Which diagnosis does the nurse anticipate? A. Bell's palsy B. Restless leg syndrome C. Peripheral nerve trauma D. Eaton-Lambert syndrome

ANS: D Eaton-Lambert syndrome is a type of myasthenia gravis that occurs with lung carcinoma. The patient experiences weakness of the pelvic muscles and shoulder muscles. Pyridostigmine is a cholinesterase inhibitor prescribed for Eaton-Lambert syndrome. Corticosteroids and antiviral medications are useful in the treatment of Bell's palsy. Antiepileptics and dopamine agonists are prescribed for restless leg syndrome. The peripheral nerves are injured in a patient with peripheral nerve trauma, and this patient does not have a history of this.

The nurse admits a patient with suspected myasthenia gravis (MG). The nurse anticipates that the health care provider will request which medication to aid in the diagnosis of MG? A. Atropine B. Morphine sulfate C. Methylprednisolone D. Edrophonium chloride

ANS: D Edrophonium chloride and neostigmine bromide may be used for testing for MG. Tensilon is used most often because of its rapid onset and brief duration of action. This drug inhibits the breakdown of acetylcholine (ACh) at the postsynaptic membrane, which increases the availability of ACh for excitation of postsynaptic receptors. Atropine has parasympatholytic effects and is the antidote for edrophonium chloride. Methylprednisolone is a glucocorticoid that is used to treat inflammatory disorders. Morphine is an opioid analgesic and is not used in the diagnosis of MG.

The nurse is reviewing the medication history of a patient diagnosed with myasthenia gravis (MG) who has been prescribed a cholinesterase inhibitor (ChE). The nurse should contact the health care provider if the patient is taking which medication? A. Ibuprofen B. Furosemide C. Procainamide D. Acetaminophen

ANS: C Procainamide should be avoided because it may increase the patient's weakness. Ibuprofen is a nonsteroidal analgesic and does not interact with ChE inhibitors. Acetaminophen does not interact with ChE inhibitors. Furosemide is a diuretic and does not interact with ChE inhibitors

A patient's spouse expresses concern that the patient, who has Guillain-Barré syndrome, is becoming very depressed and will not leave the house. What is the nurse's best response? A. "This behavior is normal." B. "Let your spouse stay alone. Your spouse will get used to it." C. "Contact the Guillain-Barré Foundation International for resources." D. "Try inviting several people over so the patient won't have to go out."

ANS: C The Guillain-Barré Syndrome Foundation International (www.gbs-cidp.org) provides resources and information for patients and their families. The patient and family should be referred to self-help and support groups for patients with chronic illness, if indicated. Inviting one close friend over is appropriate, but more than one might overwhelm the patient. Although depression is expected initially, some action does need to be taken to prevent further deterioration.

The family member of a patient with Guillain-Barré syndrome (GBS) who is receiving intravenous immunoglobulin (IVIG) asks the nurse why the provider has not ordered plasmapheresis which another family member received for this condition. What is the best response by the nurse? A. "IVIG is always tried first followed by other treatments if it fails." B. "IVIG is much less expensive and has no serious side effects." C. "Plasmapheresis is expensive and may not be covered by most insurance." D. "IVIG has been shown to be as effective as plasmapheresis in treating GBS."

ANS: D IVIG has been shown to be as effective as plasmapheresis and is immediately available in most settings. It is incorrect to tell the family member that it is not used because of cost. IVIG has serious side effects, but has shown effectiveness in treating GBS.

A patient diagnosed with ascending Guillain-Barré syndrome 2 months ago has experienced improved motor and sensory function in the upper extremities in the past few weeks. The patient asks the nurse why movement and sensation have not improved in the trunk and legs. How does the nurse respond? A. "If the legs and trunk have not improved by now, they probably won't." B. "These symptoms are characteristic of chronic Guillain-Barré syndrome." C. "You may experience recovery of sensation only in the lower extremities." D. "Complete recovery of motor and sensory function may take months to years."

ANS: D Recovery from Guillain-Barre syndrome (GBS) occurs in the opposite order that symptoms appeared, so the upper body will recover first, followed by the lower body. Complete recovery may take months to years. Chronic GBS may occur if complete recovery has not occurred after several years.

Which phase of Guillain-Barré syndrome (GBS) coincides with axonal regeneration? A. Acute phase B. Plateau period C. Chronic phase D. Recovery phase

ANS: D The recovery phase (gradually over 4 to 6 months, maybe up to 2 years) is thought to coincide with remyelination and axonal regeneration. The acute phase begins with onset of the first symptoms and ends when no further deterioration occurs. The plateau period follows the acute phase before remyelination and axonal regeneration occurs. Some patients do not completely recover and have permanent neurologic deficits, referred to as chronic GBS.