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) Prepare the client for mechanical ventilation:
A myasthenic crisis is a medical emergency characterized by severe weakness of the respiratory muscles, leading to respiratory failure. This can result from insufficient levels of acetylcholine due to insufficient medication (e.g., pyridostigmine) or from an infection. In such cases, airway support is the priority. The nurse should first prepare the client for potential mechanical ventilation to ensure they can breathe properly and to prevent respiratory arrest.

B) Instruct the client to perform pursed-lip breathing:
While pursed-lip breathing is a useful technique to help with shortness of breath and improve ventilation in certain respiratory conditions (like COPD), it is not the first action in managing a myasthenic crisis. The immediate priority is to ensure the client can breathe and maintain oxygenation, which may require mechanical ventilation if the respiratory muscles are too weak to support breathing effectively.

C) Prepare to administer IVIG:
IV immunoglobulin (IVIG) can be used in the treatment of myasthenic crisis by suppressing the immune response and increasing acetylcholine receptor activity. However, IVIG is not typically the first intervention. Respiratory support and stabilization should take precedence, especially if there is significant respiratory distress.

D) Administration of an immunosuppressant:
Immunosuppressive therapy, such as corticosteroids or azathioprine, may be used to manage myasthenia gravis over the long term, but it is not an acute intervention for a myasthenic crisis. The immediate priority in a crisis situation is to manage respiratory distress and ensure airway protection.

A. Unilateral facial drooping B. Unilateral arm weakness C. Alopecia D. Difficulty swallowing E. Inability to close the affected eye

Correct Answer is ["A"]

Explanation

A) Unilateral facial drooping:
Unilateral facial drooping is the hallmark sign of Bell's palsy, a condition that results from inflammation of the facial nerve (cranial nerve VII). This inflammation causes muscle weakness or paralysis on one side of the face, leading to drooping of the mouth, eyelid, and other facial features on the affected side. The facial drooping may worsen with smiling, closing the eyes, or other facial expressions, making this a key finding in Bell’s palsy.

B) Unilateral arm weakness:
Unilateral arm weakness is not typically associated with Bell's palsy, which specifically affects the facial muscles due to nerve damage. While weakness can occur in other parts of the body due to neurological conditions, it is not a characteristic symptom of Bell’s palsy, which is primarily a cranial nerve issue. Therefore, arm weakness would prompt consideration of other potential neurological causes.

C) Alopecia:
Alopecia, or hair loss, is not a common symptom of Bell's palsy. Although it can be seen in many different conditions, it is not typically linked with Bell's palsy, which is a disorder of the facial nerve. Bell’s palsy affects facial muscles, leading to symptoms like drooping or inability to close the eye, but it does not directly cause hair loss.

D) Difficulty swallowing:
Difficulty swallowing (dysphagia) can occur in Bell's palsy, especially if the facial nerve affects the ability to control the muscles involved in swallowing. This may lead to difficulty with chewing, swallowing, or speaking clearly. While not always severe, dysphagia is a potential complication due to the involvement of the facial nerve, which controls facial muscles essential for these functions.

E) Inability to close the affected eye:
The inability to close the affected eye is a common symptom of Bell's palsy due to paralysis of the orbicularis oculi muscle, which is controlled by the facial nerve. This can lead to dryness or irritation of the eye and a risk for corneal damage if the eye is not properly closed or protected. This inability to close the eye is one of the hallmark features of Bell's palsy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse prepare to take first?

Correct Answer is A

Explanation

A nurse is assessing a client who has been recently diagnosed with Bell's palsy. Which of the following findings should the nurse expect? [Select all that apply.]

Correct Answer is ["A"]

Explanation

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