Guillain -Barré Syndrome NCLEX Review 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/sympt oms, 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. Which statement by the clien t 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 neurologic al 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 Which assessment i ntervention 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 intrac ranial 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 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.
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 intrac ranial 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 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.
