MSN 377 Exam 4 Test Exam Questions And
Answers Verified 100% Correct
True or False: Guillain-Barré Syndrome occurs when the body's
immune system attacks the myelin sheath on the nerves in the central
nervous system.
True
False - ANSWER -FALSE:
Guillain-Barré Syndrome is an autoimmune neuro condition where the
immune system attacks the nerves (myelin sheath) in the
PERIPHERAL NERVOUS SYSTEM and cranial nerves. This condition
does NOT occur in the central nervous system (CNS).
During nursing report you learn that the patient you will be caring for
has Guillain-Barré Syndrome. As the nurse you know that this disease
tends to present with:
A. signs and symptoms that are unilateral and descending that
start in the lower extremities
B. signs and symptoms that are symmetrical and ascending that
start in the upper extremities
C. signs and symptoms that are asymmetrical and ascending that
start in the upper extremities
D. signs and symptoms that are symmetrical and ascending that
start in the lower extremities - ANSWER -The answer is D. GBS signs
and symptoms will most likely start in the lower extremities (ex: feet),
be symmetrical, and will gradually spread upward (ascending) to the
head. There are various forms of GuillainBarré Syndrome. Acute
inflammatory demyelinating polyradiculoneuropathy (AIDP) is the
most common type in the U.S.
and this is how this syndrome tends to present.
You're assessing a patient's health history for risk factors associated
with developing Guillain-Barré Syndrome. Select all the risk factors
below:
A. Recent upper respiratory infection
,B. Patient's age: 3 years old
C. Positive stool culture Campylobacter Jejuni
D. Hyperthermia
E. Epstein-Barr
F. Diabetes
G. Myasthenia Gravis - ANSWER -The answers are: A, C, and E.
Risk factors for developing Guillain-Barré Syndrome include:
experiencing upper respiratory infection, GI infection (especially from
Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination
(flu or swine flu) etc.
A 25 year-old presents to the ER with unexplained paralysis from the
hips downward. The patient explains that a few days ago her feet were
feeling weird and she had trouble walking and now she is unable to
move her lower extremities. The patient reports suffering an illness
about 2 weeks ago, but has no other health history. The physician
suspects Guillain-Barré Syndrome and orders some diagnostic tests.
Which finding below during your assessment requires immediate
nursing action?
A. The patient reports a headache.
B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities. - ANSWER
-The answer is B.
,The patient's signs and symptoms in this scenario are typical with
Guillain-Barré Syndrome. The syndrome tends to start in the lower
extremities (with paresthesia that will progress to paralysis) and
migrate upward. The respiratory system can be affected leading to
respiratory failure. Therefore, the nurse should assess for any signs
and symptoms that the respiratory system may be compromised (ex:
weak cough, shortness of breath, dyspnea...patient says it is hard to
breath etc.). The nurse should immediately report this to the MD
because the patient may need mechanical ventilation. Absent reflexes
is common in GBS and paresthesia can extend to the upper
extremities as the syndrome progresses. A headache is not common.
A patient with Guillain-Barré Syndrome has a feeding tube for
nutrition. Before starting the scheduled feeding, it is essential the
nurse? Select all that apply:
A. Assesses for bowel sounds
B. Keeps the head of bed less than 30' degrees
C. Checks for gastric residual
D. Weighs the patient - ANSWER -The answers are A and C. Some
patients who experience GBS will need a feeding tube because
they are no longer able to swallow safely due to paralysis of the
cranial nerves that help with swallowing. GBS can lead to a
decrease in gastric motility and paralytic ileus. Therefore, before
starting a scheduled feeding the nurse should always assess for
bowel sounds and check gastric residual.
You're educating a patient about treatment options for Guillain-Barré
Syndrome. Which statement by the patient requires you to re-educate
the patient about treatment?
A. "Treatments available for this syndrome do not cure the
condition but helps speed up recovery time."
B. "Plasmapheresis or immunoglobin therapies are treatment
options available for this syndrome but are most effective when given
within 4 weeks of the onset of symptoms."
, C. "When I start plasmapheresis treatment a machine will filter my
blood to remove the antibodies from my plasma that are attacking the
myelin sheath."
D. "Immunoglobulin therapy is where IV immunoglobulin from a
donor is given to a patient to stop the antibodies that are damaging
the nerves. - ANSWER -The answer is B.
This statement is incorrect. Plasmapheresis and immunoglobin
therapies are treatment options available for GBS, BUT they are only
really effective when given within 2 weeks from the onset of
symptoms (not 4 weeks).
Which tests below can be ordered to help the physician diagnose
Guillain-Barré Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies - ANSWER -The answers are C, D, and E.
These are the tests that can be ordered to help the MD determine if
the patient is experiencing GBS.
You're teaching a group of nursing students about Guillain-Barré
Syndrome and how it can affect the autonomic nervous system.
Which signs and symptoms verbalized by the students demonstrate
they understood the autonomic involvement of this syndrome? Select
all that apply:
A. Altered body temperature regulation
B. Inability to move facial muscles
C. Cardiac dysrhythmias
Answers Verified 100% Correct
True or False: Guillain-Barré Syndrome occurs when the body's
immune system attacks the myelin sheath on the nerves in the central
nervous system.
True
False - ANSWER -FALSE:
Guillain-Barré Syndrome is an autoimmune neuro condition where the
immune system attacks the nerves (myelin sheath) in the
PERIPHERAL NERVOUS SYSTEM and cranial nerves. This condition
does NOT occur in the central nervous system (CNS).
During nursing report you learn that the patient you will be caring for
has Guillain-Barré Syndrome. As the nurse you know that this disease
tends to present with:
A. signs and symptoms that are unilateral and descending that
start in the lower extremities
B. signs and symptoms that are symmetrical and ascending that
start in the upper extremities
C. signs and symptoms that are asymmetrical and ascending that
start in the upper extremities
D. signs and symptoms that are symmetrical and ascending that
start in the lower extremities - ANSWER -The answer is D. GBS signs
and symptoms will most likely start in the lower extremities (ex: feet),
be symmetrical, and will gradually spread upward (ascending) to the
head. There are various forms of GuillainBarré Syndrome. Acute
inflammatory demyelinating polyradiculoneuropathy (AIDP) is the
most common type in the U.S.
and this is how this syndrome tends to present.
You're assessing a patient's health history for risk factors associated
with developing Guillain-Barré Syndrome. Select all the risk factors
below:
A. Recent upper respiratory infection
,B. Patient's age: 3 years old
C. Positive stool culture Campylobacter Jejuni
D. Hyperthermia
E. Epstein-Barr
F. Diabetes
G. Myasthenia Gravis - ANSWER -The answers are: A, C, and E.
Risk factors for developing Guillain-Barré Syndrome include:
experiencing upper respiratory infection, GI infection (especially from
Campylobacter Jejuni), Epstein-Barr infection, HIV/AIDS, vaccination
(flu or swine flu) etc.
A 25 year-old presents to the ER with unexplained paralysis from the
hips downward. The patient explains that a few days ago her feet were
feeling weird and she had trouble walking and now she is unable to
move her lower extremities. The patient reports suffering an illness
about 2 weeks ago, but has no other health history. The physician
suspects Guillain-Barré Syndrome and orders some diagnostic tests.
Which finding below during your assessment requires immediate
nursing action?
A. The patient reports a headache.
B. The patient has a weak cough.
C. The patient has absent reflexes in the lower extremities.
D. The patient reports paresthesia in the upper extremities. - ANSWER
-The answer is B.
,The patient's signs and symptoms in this scenario are typical with
Guillain-Barré Syndrome. The syndrome tends to start in the lower
extremities (with paresthesia that will progress to paralysis) and
migrate upward. The respiratory system can be affected leading to
respiratory failure. Therefore, the nurse should assess for any signs
and symptoms that the respiratory system may be compromised (ex:
weak cough, shortness of breath, dyspnea...patient says it is hard to
breath etc.). The nurse should immediately report this to the MD
because the patient may need mechanical ventilation. Absent reflexes
is common in GBS and paresthesia can extend to the upper
extremities as the syndrome progresses. A headache is not common.
A patient with Guillain-Barré Syndrome has a feeding tube for
nutrition. Before starting the scheduled feeding, it is essential the
nurse? Select all that apply:
A. Assesses for bowel sounds
B. Keeps the head of bed less than 30' degrees
C. Checks for gastric residual
D. Weighs the patient - ANSWER -The answers are A and C. Some
patients who experience GBS will need a feeding tube because
they are no longer able to swallow safely due to paralysis of the
cranial nerves that help with swallowing. GBS can lead to a
decrease in gastric motility and paralytic ileus. Therefore, before
starting a scheduled feeding the nurse should always assess for
bowel sounds and check gastric residual.
You're educating a patient about treatment options for Guillain-Barré
Syndrome. Which statement by the patient requires you to re-educate
the patient about treatment?
A. "Treatments available for this syndrome do not cure the
condition but helps speed up recovery time."
B. "Plasmapheresis or immunoglobin therapies are treatment
options available for this syndrome but are most effective when given
within 4 weeks of the onset of symptoms."
, C. "When I start plasmapheresis treatment a machine will filter my
blood to remove the antibodies from my plasma that are attacking the
myelin sheath."
D. "Immunoglobulin therapy is where IV immunoglobulin from a
donor is given to a patient to stop the antibodies that are damaging
the nerves. - ANSWER -The answer is B.
This statement is incorrect. Plasmapheresis and immunoglobin
therapies are treatment options available for GBS, BUT they are only
really effective when given within 2 weeks from the onset of
symptoms (not 4 weeks).
Which tests below can be ordered to help the physician diagnose
Guillain-Barré Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies - ANSWER -The answers are C, D, and E.
These are the tests that can be ordered to help the MD determine if
the patient is experiencing GBS.
You're teaching a group of nursing students about Guillain-Barré
Syndrome and how it can affect the autonomic nervous system.
Which signs and symptoms verbalized by the students demonstrate
they understood the autonomic involvement of this syndrome? Select
all that apply:
A. Altered body temperature regulation
B. Inability to move facial muscles
C. Cardiac dysrhythmias
