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. Progre...
Guillain-Barré Syndrome( NCLEX )
Review Exam Questions Fully Solved.
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. - Answer 4
Ascending paralysis is the classic symptom of Guillain-Barré syndrome
1. These signs/symptoms, 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 client 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." - Answer 2
This syndrome is usually preceded by a respiratory or gastrointestinal infection one (1) to four (4) weeks
prior to the onset of neurological 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 intervention 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. - Answer 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 intracranial 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. - Answer 2.
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