GUILLAIN BARRE SYNDROME

Question 1

1. 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.

Answer 1

FALSE: Guillain-Barré Syndrome is an autoimmune neuro condition where the immune system attacks the nerves in the PERIPHERAL NERVOUS SYSTEM and cranial nerves. This condition does NOT occur in the central nervous system (CNS).

Question 2

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 2

D

Question 3

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 3

A,C,E

Question 4

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 4

B

Question 5

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 5

A,C

Question 6

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.S

Answer 6

B

Question 7

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 7

C,D,E

Question 8

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
D. Orthostatic hypotension
E. Bladder distension

Answer 8

A,C,D,E

Question 9

You’re about to send a patient for a lumbar puncture to help rule out Guillain-Barré Syndrome. Before sending the patient you will have the patient?
A. Clean the back with antiseptic
B. Drink contrast dye
C. Void
D. Wash their hair

Answer 9

C

Question 10

Your patient is back from having a lumbar puncture. Select all the correct nursing interventions for this patient?Select all that apply:

A. Place the patient in lateral recumbent position.
B. Keep the patient flat.
C. Remind the patient to refrain from eating or drinking for 4 hours.
D. Encourage the patient to consume liquids regularly.

Answer 10

B,D

Question 11

The patient’s lumbar puncture results are back. Which finding below correlates with Guillain-Barré Syndrome?

A. high glucose with normal white blood cells
B. high protein with normal white blood cells
C. high protein with low white blood cells
D. low protein with high white blood cells

Answer 11

B

Question 12

Paralysis that accompanies Guillain-Barré syndrome is only temporary.
TRUE
FALSE

Answer 12

TRUE

Question 13

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?

a. An exaggerated startle reflex and memory changes.
b. Cogwheel rigidity and inability to initiate voluntary movement.
c. Sudden severe unilateral facial pain and inability to chew.
d. Progressive ascending paralysis of the lower extremities and numbness.

Answer 13

D

Question 14

Which statement by the client supports the diagnosis of Guillain-Barré syndrome?

a. “I just returned from a short trip to Japan.”
b. “I had a really bad cold just a few weeks ago.”
c. “I think one of the people I work with had this.”
d. “I have been taking some herbs for more than a year.

Answer 14

B

Question 15

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome

a. results from an acute infection and inflammation of the peripheral nerves.
b. is due to an immune reaction that attacks the covering of the peripheral nerves.
c. is caused by destruction of the peripheral nerves after exposure to a viral infection.
d. results from degeneration of the peripheral nerve caused by viral attacks.

Answer 15

B

Question 16

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient’s illness, the most essential assessment for the nurse to carry out is

a. monitoring the cardiac rhythm continuously.
b. determining the level of consciousness q2hr.
c. evaluating sensation and strength of the extremities.
d. performing constant evaluation of respiratory function.

Answer 16

D

Question 17

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action?

a. The patient complains of severe tingling pain in the feet.
b. The patient has continuous drooling of saliva.
c. The patient’s blood pressure (BP) is 106/50 mm Hg.
d. The patient’s quadriceps and triceps reflexes are absent.

Answer 17

B

Question 18

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include

a. intubation and mechanical ventilation.
b. insertion of a nasogastric (NG) feeding tube.
c. administration of methylprednisolone (Solu-Medrol).
d. IV infusion of immunoglobulin (Sandoglobulin).

Answer 18

D

Question 19

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant?

a. Nasogastric tube feeding q4hr
b. Artificial tear administration q2hr
c. Assessment for bladder distension q2hr
d. Passive range of motion to extremities q8hr

Answer 19

D

Question 20

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the clientmostat risk for this disease?

a. Meningitis or encephalitis during the last 5 years
b. Seizures or trauma to the brain within the last year
c. Back injury or trauma to the spinal cord during the last 2 years
d. Respiratory or gastrointestinal infection during the previous month

Answer 20

D

Question 21

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring whichmost essentialitems into the client’s room?

a. Nebulizer and pulse oximeter
b. Blood pressure cuff and flashlight
c. Nasal cannula and incentive spirometer
d. Electrocardiographic monitoring electrodes and intubation tray

Answer 21

D

Question 22

Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome?

a. An exaggerated startle reflex and memory changes.
b. Cogwheel rigidity and inability to initiate voluntary movement.
c. Sudden severe unilateral facial pain and inability to chew.
d. Progressive ascending paralysis of the lower extremities and numbness.

Answer 22

D

Question 23

Which statement by the client supports the diagnosis of Guillain-Barré syndrome?

a. “I just returned from a short trip to Japan.”
b. “I had a really bad cold just a few weeks ago.”
c. “I think one of the people I work with had this.”
d. “I have been taking some herbs for more than a year.”

Answer 23

B

Question 24

Which assessment intervention should the nurse implement specifically for the diagnosis of Guillain-Barré syndrome?

a. Assess deep tendon reflexes.
b. Complete a Glasgow Coma Scale.
c. Check for Babinski’s reflex.
d. Take the client’s vital signs.

Answer 24

A

Question 25

The health-care provider scheduled a lumbar puncture for a client admitted with rule-out Guillain-Barré syndrome. Which pre procedure intervention has priority?

a. Keep the client NPO.
b. Instruct the client to void.
c. Place in the lithotomy position.
d. Assess the client’s pedal pulse.

Answer 25

B

Question 26

Which priority client problem should be included in the care plan for the client diagnosed with Guillain-Barré syndrome?

a. High risk for injury.
b. Fear and anxiety.
c. Altered nutrition.
d. Ineffective breathing pattern.

Answer 26

D

Question 27

The nurse caring for the client diagnosed with Guillain-Barré syndrome writes the client problem “impaired physical mobility.” Which long-term goal should be written for this problem?

a. The client will have no skin irritation.
b. The client will have no muscle atrophy.
c. The client will perform range-of-motion exercises.
d. The client will turn every two (2) hours while awake.

Answer 27

B

Question 28

The client diagnosed with Guillain-Barré syndrome is on a ventilator. Which intervention will assist the client to communicate with the nursing staff?

a. Provide an erase slate board for the client to write on
b. Instruct the client to blink once for “no” and twice for “yes.”
c. Refer to a speech therapist to help with communication.
d. Leave the call light within easy reach of the client.

Answer 28

B

Question 29

The client admitted with rule-out Guillain-Barré syndrome has just had a lumbar puncture. Which intervention should the nurse implement post procedure?

a. Monitor the client for hypotension.
b. Apply pressure to the puncture site.
c. Test the client’s cerebrospinal fluid.
d. Increase the client’s fluid intake.

Answer 29

D

Question 30

The client diagnosed with Guillain-Barré syndrome is having difficulty breathing and is placed on a ventilator. Which situation warrants immediate intervention by the nurse?

a. The ventilator rate is set at 14 breaths per minute.
b. A manual resuscitation bag is at the client’s bedside.
c. The client’s pulse oximeter reading is 85%.
d. The ABG results are pH 7.40, PaO288, PaCO235, and HCO324.

Answer 30

C