A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

Unilateral upper extremity weakness

Bilateral ascending weakness

Mask like facial expressions

Pill rolling actions made by the clients fingers

Answer and Explanation

The Correct Answer is B

A) Unilateral upper extremity weakness:
Guillain-Barré Syndrome (GBS) typically presents with bilateral weakness, not unilateral. The weakness in GBS typically begins symmetrically in the lower extremities and ascends upward toward the upper body, including the arms, face, and respiratory muscles. Therefore, unilateral weakness is not characteristic of GBS, and its presence should prompt further investigation into other possible causes.

B) Bilateral ascending weakness:
One of the hallmark signs of Guillain-Barré Syndrome is ascending weakness, which means that the weakness usually starts in the lower extremities (legs) and progresses upwards to the upper extremities, face, and potentially the respiratory muscles. This bilateral ascending paralysis is a classic feature of GBS and occurs due to the immune system attacking the myelin sheath of peripheral nerves. The nurse should be vigilant for signs of progressive weakness, as GBS can quickly lead to respiratory failure and requires prompt intervention.

C) Mask-like facial expressions:
Mask-like facial expressions are more commonly associated with Parkinson's disease, not Guillain-Barré Syndrome. Parkinson’s disease is characterized by a reduction in facial expressiveness due to the loss of dopaminergic neurons, leading to a fixed, unblinking, or "masked" appearance. While facial involvement can occur in GBS as the weakness ascends, it is not typically described as a "mask-like" expression.

D) Pill rolling actions made by the client's fingers:
Pill-rolling is a characteristic tremor often associated with Parkinson's disease and involves the repetitive motion of the fingers, as if rolling a pill. It is a resting tremor seen in Parkinson's disease and not in Guillain-Barré Syndrome. GBS primarily presents as weakness and loss of motor function, rather than tremors or other involuntary movements.

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Correct Answer is A

Explanation

A) Spironolactone:
Spironolactone is a potassium-sparing diuretic commonly used in the treatment of heart failure. Unlike other diuretics, spironolactone works by antagonizing aldosterone, a hormone that promotes sodium and water retention and potassium excretion. By blocking aldosterone's action, spironolactone prevents the kidneys from excreting potassium, thus increasing potassium levels in the blood (hyperkalemia). Additionally, spironolactone can lead to hyponatremia (low sodium levels), as it also causes the kidneys to retain sodium and water, diluting sodium levels in the blood.

B) Furosemide:
Furosemide, a loop diuretic, is typically used in heart failure to remove excess fluid. It works by inhibiting the reabsorption of sodium, chloride, and potassium in the loop of Henle, which increases urine output. While furosemide can cause hypokalemia (low potassium levels) due to the increased excretion of potassium, it does not typically cause hyperkalemia.

C) Hydrochlorothiazide:
Hydrochlorothiazide is a thiazide diuretic, which works by inhibiting sodium and chloride reabsorption in the distal convoluted tubule of the kidney, leading to increased urine production. Thiazide diuretics can cause hypokalemia (low potassium levels) and hyponatremia (low sodium levels) due to the enhanced excretion of both electrolytes.

D) Metolazone:
Metolazone is also a thiazide-like diuretic that works similarly to hydrochlorothiazide. It can cause hypokalemia and hyponatremia, but like hydrochlorothiazide, it does not typically cause hyperkalemia. Metolazone is more potent than hydrochlorothiazide but still does not carry the risk of hyperkalemia like spironolactone does.

A. Normal saline 1 liter to client who is dehydrated B. Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain C. Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain D. Lorazepam 2 mg IV now for the client who is anxious and restless

Correct Answer is C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

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A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

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