Patho Patho #60

Question

The nurse caring for a client with Guillain-Barre syndrome places priority on which assessment finding?

Answers

  1. Reports of lower extremity muscle weakness.
    • Rationale:

      This answer choice is not correct because lower extremity muscle weakness is an expected finding in a client with Guillain Barre and is therefore not a critical assessment finding.

  2. A blood pressure of 104/72.
    • Rationale:

      This answer choice is not correct because a blood pressure of 104/72 is considered acceptable with adequate organ and tissue perfusion. This is therefore not a critical assessment finding in a client with Guillain Barre.

  3. Capillary refill time of 4 seconds.
    • Rationale:

      This answer choice is not correct because a critically low oxygen saturation is a higher priority than an increased capillary refill time.

  4. O2 saturation of 82%.
    • Rationale:

      This answer is correct because an oxygen saturation of 82% in a client with Guillain Barre is a sign of possible impending respiratory failure. The nurse should prepare to intubate this client with mechanical intubation.

Overview

The focus of this question is asking the nurse to determine the most critical assessment finding in a client with Guillain Barre syndrome. Guillain Barre is a progressive neurological disorder that affects the peripheral nerves in an ascending manner. It is usually triggered by an infectious process that causes the immune system to overreact and attack the peripheral nerves. Paralysis affects the clients extremities eventually ascending to the respiratory muscles. An oxygen saturation of 82% alerts the nurse to impending respiratory failure and is the most critical finding in this client.

Explanation

Learning Outcomes

Clients with Guillain Barre syndrome is a very rapid onset muscle weakness caused by the immune system damaging the peripheral nerve system. The muscle weakness usually begins in the distal extremities and ascends to the upper body. Muscle weakness can ascend to the upper body within hours of the onset of symptoms. The most critical potential complication of Guillain Barre is respiratory failure so a decreased oxygen saturation must be addressed immediately by the nurse.

Test Taking Tip

A-B-C

Video Rationale