early recognition
a pt reports numbness and tingling in both feet 2 weeks after a viral illness. over the next 48 hours they develop weakness that moves upward. what is this patient most likely experiencing?
A. multiple sclerosis
B. stroke
C. myasthenia graves
D. Guillain- barre syndrome
Answer D
rationale: GBS presents as ascending, symmetric weakness after an infection
what is the primary problem in GBS?
A. Neuron death
B. Demyelination of peripheral nerves
C. Excess neurotransmitters
D. Muscle degeneration
Answer: B
Rationale: GBS causes segmental demyelination = slowed nerve conduction
which complications should the nurse monitor for in GBS?
A. Respiratory failure
B. Hypertension
C. Bradycardia
D. Seizures
E. Diaphoresis
Answer: A, B, C, E
Rationale: Autonomic dysfunction causes these issues
A nurse reviews CSF results for a pt suspected of GBS. Which finding supports the diagnosis?
A. Low protein
B. High protein
C. Low glucose
D. High WBC
Answer: B
Rationale: GBS is associated with elevated CSF protein levels due to nerve inflammation and demylenation
which assessments are most important for a pt with GBS?
A. Motor function
B. Reflexes
C. Cranial nerve function
D. Level of consciousness
E. Hair distribution
Answer: A, B, C, D
Rationale: Monitoring progression of GBS requires assessing motor strength, reflexes, cranial nerves, and LOC to detect worsening paralysis or complications
which early findings would the nurse expect in GBS?
A. Paresthesia
B. Hyperreflexia
C. Hypotonia
D. Pain
E. Spastic paralysis
Answer: A,C,D
Rationale:
early signs include pain, paresthesia, hypotonia. reflexes are decreased not increased
which process occurs in GBS?
A. Immune attack on nerves
B. Myelin destruction
C. Increased nerve conduction
D. Edema and inflammation
E. Remyelination during recovery
Answer: A,B,D,E
Rationale: Immune- mediated demyelination, and later is remyelination
which complication is the MOST life threatening?
A. Pain
B. Paralysis
C. Respiratory failure
D. Extreme fatigue
Answer: C
Rationale: Respiratory muscle involvement can require ventilation
which treatments are appropriate for pt's with GBS?
A. Plasmapheresis
B. IV immunoglobulin (IVIG)
C. Antibiotics
D. Immunomodulation
E. Steroids only
Answer: A, B, D
Rationale: GBS is treated with plasmapheresis and IVIG, both of which are forms of immunomodulation. Antibiotics are not indicated unless there is a separate infection
Which pt requires immediate intervention?
A. Reports sudden onset of tingling in feet
B. Has decreased reflexes
C. Develops difficulty breathing
D. Complains of severe fatigue
Answer: C
Rationale: difficulty breathing indicated impending respiratory failure, which is the highest priority in GBS.
A nurse is assessing a satinet suspected of GBS. which finding is most concerning?
A. Symmetric weakness
B. Absent reflexes
C. Difficulty swallowing
D. Mild tingling
Answer: C
Rationale: dysphagia = cranial nerve involvement and that puts the airway at risk
why does weakness occur in GBS?
A. loss of blood supply
B. muscle rupture
C. blocked nerve impulse transmission
D brain damage
Answer: C
rationale: demylenation slows or stops nerve signals
Which signs indicate autonomic dysfunction?
A. Orthostatic hypotension
B. Facial flushing
C. Stable heart rate
D. Bowel dysfunction
E. Abnormal sweating
Answer: A, B, D, E
Rationale: All are autonomic effects
when is tx most effective for GBS?
A. Within the first 2 weeks
B. After full paralysis
C. During recovery phase
D. Only in severe cases
Answer: A
Rationale: Immunomodulating therapies are most effective when started early (within the first 2 weeks) of symptom onset
which nursing interventions are appropriate for pt's with GBS?
A. Prevent DVT
B. Prevent pressure ulcers
C. Encourage independent ambulation
D. Monitor for aspiration
E. Assist with ADLs
Answer: A, B, D, E
Rationale: Patients are often weak/paralyzed, requiring full support, and are at risk for immobility complications and aspiration
which characteristics are consistent wit GBS?
A. Ascending paralysis
B. Symmetric weakness
C. Rapid progression
D. Hyperactive reflexes
E. Peak weakness within 4 weeks
Rationale: GBS=. ascending, symmetrical, rapid progression and it peaks within the 4 week time frame
which factors are associated with poor prognosis?
A. Older age
B. Rapid onset
C. Mechanical ventilation
D. Mild symptoms
E. Early recovery
Answer: A, B, C
Rationale: These are listed risk factors for worse outcomes
A pt with GBS suddenly developed bradycardia and hypotension. What is the cause?
A. Infection
B. Autonomic dysfunction
C. Medication reaction
D. Dehydration
Answer: B
Rationale: GBS cause autonomic dysfunction leading to unstable vital signs because of impaired nerve regulation of the heart and other vessels
which diagnostic test help confirm GBS?
A. EMG
B. Nerve conduction studies
C. CT scan
D. CSF analysis
E. X-ray
Answer: A, B, D
Rationale: Diagnosis is supported by CSF analysis (↑ protein) and confirmed with EMG and nerve conduction studies
a pt loses their gag reflex. what is the nurses priority action?
A. continue oral feeding as usual
B. encourage them to take fluids
C. insert a feeding tube
D. come back and reassess them after 15 min
Answer: C
Rationale: loss of gag reflex is a high aspiration risk so oral intake should be stopped and enteral feedings should be used
A pt's weakness began in the legs and is now affecting the arms. what phase is this patient most likely in?
A. Recovery phase
B. Remission
C. Progressive phase
D. Chronic phase
Answer: C
Rationale: ascending weakness = the progressive phase
during recovery, what occurs first?
A. distal nerve function returns
B. pain worsens
C. Reflexes increase immediately
D. proximal nerve function returns
Answer: D
Rationale: recovery usually occurs proximal to distal
which complications should the nurse prioritize in a pt with GBS?
A. Deep vein thrombosis
B. Pressure ulcers
C. Aspiration
D. Ileus
E. Hyperactivity
Answer: A, B, C, D
Rationale: Due to immobility and autonomic dysfunction, patients are at risk for DVT, pressure injuries, aspiration (loss of gag reflex), and bowel dysfunction (ileus). Hyperactivity is not associated with GBS
What is the primary goal of plasmapheresis?
A. Increase oxygenation
B. Remove antibodies from blood
C. Increase RBC production
D. Reduce pain
Answer: B
Rationale: Plasmapheresis works by removing circulating antibodies that are attacking the peripheral nerves
which complications related to autonomic dysfunction should the nurse monitor for?
A. Hypertension
B. Hypotension
C. Dysrhythmias
D. Diaphoresis
E. Hyperactivity
Answer: A, B, C, D
Rationale: Autonomic dysfunction in GBS causes unstable BP, abnormal heart rhythms, and sweating abnormalities