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 D

Explanation

A. Intense pruritus (itching) noted during the assessment of the moles: While intense itching can be associated with skin changes and should be monitored, it is not a definitive sign of malignancy. However, it can be an early indicator that warrants further investigation, especially if accompanied by other changes in the mole.

B. Purulent drainage coming out of the moles: Purulent drainage typically indicates an infection rather than malignancy. While infections are serious and require treatment, they are not usually linked to skin cancer. This finding should prompt further assessment and appropriate wound care.

C. A healed sore noted upon assessment: A healed sore generally indicates that the area has resolved and is not immediately concerning. However, a non-healing or recurrent sore could be a sign of skin cancer and would need further evaluation by a healthcare provider.

D. The mole is larger than 6mm: A mole larger than 6mm is a significant indicator for potential malignancy, as size is one of the criteria in the ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) used for identifying melanoma. Larger moles warrant further examination to rule out skin cancer.

A. "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication." B. "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function." C. "Before you lose cognitive function, you should consider creating an advanced directive." D. "Despite severe symptoms right now, most patients recover with treatment."

Correct Answer is B

Explanation

A) "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication."
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in the progressive loss of motor neurons, which leads to muscle weakness, atrophy, and paralysis. It is not caused by "excess chemicals in the brain," and there are currently no medications that can cure ALS or completely control its symptoms. Medications such as riluzole can slow the progression slightly, but they do not stop or reverse the disease.

B) "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function."
ALS is indeed a progressive neurodegenerative disease that leads to the gradual loss of muscle function due to the death of motor neurons. Over time, the patient will experience muscle weakness, atrophy, and paralysis, while the cognitive function typically remains intact until the later stages of the disease, although some patients may develop frontotemporal dementia. it is essential for the patient to understand that the disease will progressively impair their physical abilities while leaving cognitive functions largely unaffected in most cases.

C) "Before you lose cognitive function, you should consider creating an advanced directive."
While it is important for individuals with ALS to plan for the future, this statement is not entirely accurate. Cognitive function in ALS is often preserved throughout most of the disease, although there is a subset of patients who may develop frontotemporal dementia. It would be more appropriate to discuss advanced directives early in the disease, but it is not guaranteed that cognitive function will be lost before physical decline.

D) "Despite severe symptoms right now, most patients recover with treatment."
ALS is a progressive disease with no cure, and it does not typically result in recovery. While certain treatments can help manage symptoms or slow the progression of the disease, recovery is not a realistic expectation. Most patients with ALS experience gradual worsening of symptoms and ultimately may require assistance with daily activities as the disease progresses.

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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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