Which of the following statements regarding Guillain-Barre syndrome are accurate? Select all that apply.
It is an autoimmune disorder affecting the peripheral nervous system.
It is commonly associated with gastrointestinal disorders.
Reye's syndrome is a variant of Guillain-Barre syndrome.
Guillain-Barre syndrome can lead to respiratory muscle weakness.
It primarily affects females more than males.
Symptoms typically start in the limbs and progress upwards.
Correct Answer : A,B,D,F
Choice A rationale
This is accurate as it is an acute inflammatory demyelinating polyneuropathy. The immune system mistakenly attacks the myelin sheath of the peripheral nerves, which slows or blocks the conduction of nerve impulses. This autoimmune response is often triggered by a preceding infection. The destruction of myelin leads to varying degrees of muscle weakness and sensory loss. Early recognition is vital for initiating treatments like plasmapheresis or intravenous immunoglobulin therapy to limit nerve damage.
Choice B rationale
This is accurate because many cases are preceded by a gastrointestinal infection, most notably by the bacterium Campylobacter jejuni. Respiratory infections are also common triggers. The theory of molecular mimicry suggests that the immune system produces antibodies against the infecting pathogen that cross-react with similar antigens on the peripheral nerve myelin. This link between a recent illness and the onset of neurological symptoms is a key diagnostic feature used during the patient's history taking.
Choice C rationale
This is inaccurate because Reye's syndrome is a completely different condition characterized by acute encephalopathy and fatty infiltration of the liver, typically following a viral illness in children who took aspirin. Miller Fisher syndrome, not Reye's syndrome, is the well-known variant of this condition, characterized by the triad of ataxia, areflexia, and ophthalmoplegia. Confusing these two syndromes could lead to incorrect diagnostic paths and inappropriate management strategies for the affected patient.
Choice D rationale
This is accurate and represents the most serious complication of the syndrome. As the ascending paralysis progresses, it can reach the intercostal muscles and the diaphragm. This leads to acute respiratory failure, necessitating frequent monitoring of forced vital capacity and negative inspiratory force. Up to thirty percent of patients may require mechanical ventilation during the peak of the illness. Prompt transfer to an intensive care unit is required if respiratory involvement is suspected.
Choice E rationale
This is inaccurate as the condition slightly favors males more than females, and it can affect individuals of any age. Unlike many other autoimmune diseases that have a strong female predominance, this syndrome does not show that pattern. Epidemiological studies consistently show a slightly higher incidence in men. Understanding the demographic distribution helps clinicians maintain a high index of suspicion in any patient presenting with rapid, symmetrical, ascending motor weakness regardless of their gender.
Choice F rationale
This is accurate as the classic presentation involves symmetrical weakness and paresthesia that begins in the feet and legs and moves toward the trunk and upper body. This is often referred to as ascending paralysis. The loss of deep tendon reflexes, such as the Achilles and patellar reflexes, usually accompanies the muscle weakness. This characteristic pattern of progression is a hallmark of the disease and helps distinguish it from other neurological disorders that might present more randomly. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Fatigue is a universal side effect associated with both radiation therapy and chemotherapy. In radiation, it results from the energy required for cellular repair and the accumulation of metabolic waste from cell death. In chemotherapy, it is often linked to anemia, systemic inflammation, and the cytotoxic effects on healthy tissues. Because both treatments involve systemic or localized cellular destruction and require significant physiological recovery, fatigue is a common finding shared by both modalities.
Choice B rationale
Night sweats are typically associated with the underlying malignancy itself, such as lymphoma or advanced pancreatic cancer, rather than being a specific side effect of radiation or chemotherapy. While systemic reactions can occur, night sweats are more frequently a symptom of the body's inflammatory response to the tumor or an indication of infection. They are not classified as a standard, predictable side effect of either treatment modality in the same way that cytopenias or enteritis are.
Choice C rationale
Weight loss is a common finding for both radiation and chemotherapy. Radiation to the abdominal area causes gastrointestinal upset and malabsorption, while chemotherapy induces systemic nausea, vomiting, and alterations in taste. Both treatments can lead to a state of cachexia where the body breaks down muscle and fat stores faster than they can be replenished. Nutritional support is a primary concern for patients undergoing these therapies to combat treatment-induced weight loss.
Choice D rationale
Pale skin, or pallor, is associated with both radiation and chemotherapy due to their impact on the bone marrow. Chemotherapy is systemically myelosuppressive, leading to decreased red blood cell production and anemia. While radiation is localized, if the treatment field includes bone-marrow-producing areas like the pelvis or spine, it can also contribute to lower hemoglobin levels. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the visible paleness of the skin and mucous membranes.
Correct Answer is D
Explanation
Choice A rationale
While notifying the healthcare provider is necessary, it is not the most immediate priority when the patient shows signs of hemodynamic instability. The nurse must first intervene to stabilize the patient's circulatory volume. Postoperative patients who have had surgery for Cushing's disease are at high risk for acute adrenal insufficiency. This occurs because the remaining adrenal tissue may be atrophied and unable to produce sufficient cortisol, leading to a life-threatening addisonian crisis.
Choice B rationale
Increasing oxygen flow may be supportive, but it does not address the underlying physiological cause of low blood pressure and tachycardia in this specific postoperative context. The primary issue is likely a lack of circulating cortisol and subsequent fluid volume deficit or vasodilation. While maintaining oxygen saturation is part of standard PACU care, it will not correct the hypotension or the potential adrenal crisis that is developing, making it a secondary intervention in this scenario.
Choice C rationale
Encouraging deep breaths is a standard intervention to prevent atelectasis and improve respiratory function after general anesthesia. However, it is not a priority when the patient is exhibiting signs of shock, such as hypotension and tachycardia. These vital sign changes suggest a cardiovascular or endocrine emergency rather than a primary respiratory problem. The nurse must focus on interventions that will restore blood pressure and ensure adequate organ perfusion to prevent further deterioration.
Choice D rationale
Administering IV fluids is the priority action to treat hypotension and tachycardia, which are signs of potential acute adrenal insufficiency or hypovolemia. In the absence of high cortisol levels after removing a tumor, the body cannot maintain vascular tone or fluid balance effectively. Rapid fluid resuscitation helps restore circulating volume and blood pressure. Following fluid initiation, the nurse should also prepare to administer parenteral hydrocortisone as ordered to replace the missing adrenal hormones.
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