7. A patient with Guillain-Barré syndrome asks the nurse Correct Answer: B
what has caused the disease. In responding to the patient, Rationale: Guillain-Barré syndrome is believed to result from an immunologic
the nurse explains that Guillain-Barré syndrome reaction that damages the myelin sheath of the peripheral nerves. Acute infection
a. results from an acute infection and inflammation of the or inflammation of the nerves is not a cause. The peripheral nerves are not
peripheral nerves. destroyed and do not degenerate.
b. is due to an immune reaction that attacks the covering
of the peripheral nerves. Cognitive Level: Comprehension Text Reference: pp. 1585-1586
c. is caused by destruction of the peripheral nerves after Nursing Process: Implementation NCLEX: Physiological Integrity
exposure to a viral infection.
d. results from degeneration of the peripheral nerve
caused by viral attacks.
8. A 24-year-old patient is hospitalized with the onset of Correct Answer: D
Guillain-Barré syndrome. During this phase of the Rationale: The most serious complication of Guillain-Barré syndrome is
patient's illness, the most essential assessment for the respiratory failure, and the nurse should monitor respiratory function
nurse to carry out is continuously. The other assessments will also be included in nursing care, but they
a. monitoring the cardiac rhythm continuously. are not as important as respiratory assessment.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities. Cognitive Level: Comprehension Text Reference: p. 1586
d. performing constant evaluation of respiratory function. Nursing Process: Assessment NCLEX: Physiological Integrity
, 9. When caring for a patient who has Guillain-Barré Correct Answer: B
syndrome, which assessment data obtained by the nurse Rationale: Drooling indicates decreased ability to swallow, which places the
will require the most immediate action? patient at risk for aspiration and requires rapid nursing and collaborative actions
a. The patient complains of severe tingling pain in the such as suctioning and possible endotracheal intubation. The foot pain should be
feet. treated with appropriate analgesics, and the BP requires ongoing monitoring, but
b. The patient has continuous drooling of saliva. these actions are not as urgently needed as maintenance of respiratory function.
c. The patient's blood pressure (BP) is 106/50 mm Hg. Absence of the reflexes should be documented, but this is a common finding in
d. The patient's quadriceps and triceps reflexes are absent. Guillain-Barré syndrome.
Cognitive Level: Application Text Reference: pp. 1586-1587
Nursing Process: Assessment NCLEX: Physiological Integrity
10. A patient who has numbness and weakness of both Correct Answer: D
feet is hospitalized with Guillain-Barré syndrome. The Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as
nurse will anticipate that collaborative interventions at evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to
this time will include reduce the extent and length of symptoms. Mechanical ventilation and tube
a. intubation and mechanical ventilation. feedings may be used later in the progression of the syndrome but are not needed
b. insertion of a nasogastric (NG) feeding tube. now. Corticosteroid use is not helpful in reducing the duration or symptoms of the
c. administration of methylprednisolone (Solu-Medrol). syndrome.
d. IV infusion of immunoglobulin (Sandoglobulin).
Cognitive Level: Application Text Reference: p. 1586
Nursing Process: Implementation NCLEX: Physiological Integrity
what has caused the disease. In responding to the patient, Rationale: Guillain-Barré syndrome is believed to result from an immunologic
the nurse explains that Guillain-Barré syndrome reaction that damages the myelin sheath of the peripheral nerves. Acute infection
a. results from an acute infection and inflammation of the or inflammation of the nerves is not a cause. The peripheral nerves are not
peripheral nerves. destroyed and do not degenerate.
b. is due to an immune reaction that attacks the covering
of the peripheral nerves. Cognitive Level: Comprehension Text Reference: pp. 1585-1586
c. is caused by destruction of the peripheral nerves after Nursing Process: Implementation NCLEX: Physiological Integrity
exposure to a viral infection.
d. results from degeneration of the peripheral nerve
caused by viral attacks.
8. A 24-year-old patient is hospitalized with the onset of Correct Answer: D
Guillain-Barré syndrome. During this phase of the Rationale: The most serious complication of Guillain-Barré syndrome is
patient's illness, the most essential assessment for the respiratory failure, and the nurse should monitor respiratory function
nurse to carry out is continuously. The other assessments will also be included in nursing care, but they
a. monitoring the cardiac rhythm continuously. are not as important as respiratory assessment.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities. Cognitive Level: Comprehension Text Reference: p. 1586
d. performing constant evaluation of respiratory function. Nursing Process: Assessment NCLEX: Physiological Integrity
, 9. When caring for a patient who has Guillain-Barré Correct Answer: B
syndrome, which assessment data obtained by the nurse Rationale: Drooling indicates decreased ability to swallow, which places the
will require the most immediate action? patient at risk for aspiration and requires rapid nursing and collaborative actions
a. The patient complains of severe tingling pain in the such as suctioning and possible endotracheal intubation. The foot pain should be
feet. treated with appropriate analgesics, and the BP requires ongoing monitoring, but
b. The patient has continuous drooling of saliva. these actions are not as urgently needed as maintenance of respiratory function.
c. The patient's blood pressure (BP) is 106/50 mm Hg. Absence of the reflexes should be documented, but this is a common finding in
d. The patient's quadriceps and triceps reflexes are absent. Guillain-Barré syndrome.
Cognitive Level: Application Text Reference: pp. 1586-1587
Nursing Process: Assessment NCLEX: Physiological Integrity
10. A patient who has numbness and weakness of both Correct Answer: D
feet is hospitalized with Guillain-Barré syndrome. The Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as
nurse will anticipate that collaborative interventions at evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to
this time will include reduce the extent and length of symptoms. Mechanical ventilation and tube
a. intubation and mechanical ventilation. feedings may be used later in the progression of the syndrome but are not needed
b. insertion of a nasogastric (NG) feeding tube. now. Corticosteroid use is not helpful in reducing the duration or symptoms of the
c. administration of methylprednisolone (Solu-Medrol). syndrome.
d. IV infusion of immunoglobulin (Sandoglobulin).
Cognitive Level: Application Text Reference: p. 1586
Nursing Process: Implementation NCLEX: Physiological Integrity
