A 38-year-old male patient is admitted to the hospital with progressive muscle weakness and tingling sensations. He reports a recent upper respiratory infection. On examination, he exhibits ascending paralysis. The nurse suspects Guillain-Barré Syndrome. What diagnostic test is most likely to confirm this suspicion?
A) Chest X-ray
B) Lumbar puncture
C) Electrocardiogram (ECG)
D) Magnetic Resonance Imaging (MRI)
E) Complete Blood Count (CBC)
Rationale: Guillain-Barré Syndrome (GBS) is often diagnosed through cerebrospinal fluid analysis obtained by lumbar puncture. An elevated protein level with a normal cell count is a characteristic finding in GBS, indicating an inflammatory process affecting the peripheral nervous system. Correct Answer: B) Lumbar puncture
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A patient with Guillain-Barré Syndrome is experiencing respiratory distress. Which intervention should the nurse prioritize to manage this complication?
A) Administering intravenous antibiotics
B) Initiating anticoagulant therapy
C) Providing mechanical ventilation
D) Administering corticosteroids
E) Facilitating physical therapy
Correct Answer: C) Providing mechanical ventilation
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Rationale: Respiratory failure is a severe complication of Guillain-Barré Syndrome. Mechanical ventilation is a critical intervention to support the patient’s breathing when respiratory muscles become paralyzed, preventing hypoxia and respiratory acidosis.
NCLEX Review: Guillain-Barre Disease Treatments
A nurse is caring for a client with Guillain-Barré Syndrome who is at risk for autonomic dysfunction. Which assessment finding indicates the need for immediate intervention?
A) Bradycardia
B) Hypertension
C) Hypothermia
D) Hypoactive bowel sounds
E) Increased respiratory rate
Correct Answer: A) Bradycardia
Rationale: Autonomic dysfunction is common in Guillain-Barré Syndrome, and bradycardia is a serious manifestation. It suggests involvement of the autonomic nervous system and may require prompt intervention, such as atropine administration, to address the dysregulation.
Understanding Guillain-Barre: NCLEX Priority Questions
A client recovering from Guillain-Barré Syndrome is being discharged. Which teaching point is essential for the nurse to include in the discharge plan?
A) Regular aerobic exercise routine
B) Avoidance of all vaccinations
C) Frequent hot baths for muscle relaxation
D) Use of over-the-counter muscle relaxants
E) Importance of follow-up neurology appointments
Correct Answer: E) Importance of follow-up neurology appointments
Rationale: Follow-up neurology appointments are crucial for monitoring the ongoing recovery and identifying any potential complications or residual effects of Guillain-Barré Syndrome. Regular medical follow-up helps ensure comprehensive care and timely intervention if needed.
Understanding Guillain-Barre: NCLEX Delegation Questions
A 45-year-old female presents to the emergency department with weakness and tingling in her lower extremities. She reports a recent gastrointestinal infection. The nurse suspects Guillain-Barré Syndrome (GBS). What is the primary pathophysiological mechanism underlying GBS?
A) Antibody-mediated destruction of myelin
B) Axonal degeneration
C) Impaired neuromuscular transmission
D) Autoimmune destruction of motor neurons
E) Neurotransmitter imbalance
Correct Answer: A) Antibody-mediated destruction of myelin
Rationale: Guillain-Barré Syndrome is characterized by an autoimmune response where antibodies attack the peripheral nerves, leading to demyelination. This process disrupts nerve conduction and results in the weakness and paralysis observed in GBS.
Understanding Guillain-Barre: Causes and Symptoms
A patient with Guillain-Barré Syndrome is admitted to the intensive care unit. The nurse observes decreased deep tendon reflexes and muscle weakness progressing from the legs to the arms. What nursing intervention is a priority in the care of this patient?
A) Encouraging active range of motion exercises
B) Administering high-dose corticosteroids
C) Monitoring vital signs and respiratory function
D) Applying warm compresses to affected limbs
E) Administering anticoagulant therapy
Correct Answer: C) Monitoring vital signs and respiratory function
Rationale: The priority in caring for a patient with Guillain-Barré Syndrome is monitoring vital signs and respiratory function due to the potential for respiratory failure. Close observation ensures early detection of respiratory distress and the need for interventions such as mechanical ventilation.
NCLEX Practice Questions: Understanding Guillain-Barre Causes and Symptoms
A client with Guillain-Barré Syndrome is prescribed intravenous immunoglobulin (IVIG) therapy. The client asks the nurse about the purpose of this treatment. What is the nurse’s best response?
A) “IVIG helps strengthen your muscles.”
B) “It reduces inflammation in your joints.”
C) “It boosts your immune system.”
D) “IVIG prevents further nerve damage.”
E) “It eliminates the virus causing the syndrome.”
Correct Answer: D) “IVIG prevents further nerve damage.”
Rationale: Intravenous immunoglobulin (IVIG) is used in Guillain-Barré Syndrome to modulate the immune response and prevent further nerve damage. IVIG contains antibodies that may help regulate the immune system and reduce the severity and duration of the illness.
NCLEX Questions: Focus on Medications for Guillain-Barre
A 30-year-old male is admitted to the hospital with symptoms of Guillain-Barré Syndrome (GBS), including ascending paralysis and difficulty swallowing. The healthcare team suspects autonomic dysfunction. What clinical manifestation is indicative of autonomic dysfunction in GBS?
A) Hyperactivity
B) Tachycardia
C) Bradycardia
D) Hypertension
E) Increased bowel sounds
Correct Answer: C) Bradycardia
Rationale: Autonomic dysfunction in Guillain-Barré Syndrome often manifests as bradycardia. The involvement of the autonomic nervous system can lead to dysregulation of heart rate, and bradycardia is a critical sign that may require prompt intervention to stabilize the patient.
NCLEX Focus Exploring Guillain-Barre: Causes and Diagnosis
A nurse is caring for a patient diagnosed with Guillain-Barré Syndrome (GBS) who is experiencing muscle weakness and difficulty ambulating. What is the most appropriate nursing intervention to promote mobility and prevent complications?
A) Administering high-dose corticosteroids
B) Placing the patient in a knee immobilizer
C) Encouraging bed rest for 48 hours
D) Facilitating physical therapy exercises
E) Administering muscle relaxants
Correct Answer: D) Facilitating physical therapy exercises
Rationale: Physical therapy is essential in the management of Guillain-Barré Syndrome to prevent complications such as contractures and promote optimal mobility. Exercises help maintain joint flexibility, strengthen muscles, and improve overall function during the recovery process.
A client with Guillain-Barré Syndrome is being discharged from the hospital. The nurse provides education on potential complications. Which statement by the client indicates a need for further clarification?
A) “I should report any new tingling or weakness.”
B) “I can resume my regular exercise routine immediately.”
C) “I’ll follow up with my neurologist as scheduled.”
D) “I need to be cautious of respiratory symptoms.”
E) “I’ll avoid large crowds to prevent infections.”
Correct Answer: B) “I can resume my regular exercise routine immediately.”
Rationale: While exercise is beneficial for overall health, a client recovering from Guillain-Barré Syndrome should follow a gradual and supervised exercise program. Resuming a regular exercise routine immediately may pose a risk of overexertion and exacerbate muscle weakness. Further clarification and guidance on a safe exercise plan are needed.