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NCLEX-RN · Question #487

NCLEX-RN Question #487: Real Exam Question with Answer & Explanation

The correct answer is C. Complaints of shortness of breath. (A) Headaches are not associated with Guillain-Barr?syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness

Question

A 32-year-old female client is being treated for Guillain- Barr?syndrome. She complains of gradually increasing muscle weakness over the past several days. She has noticed an increased difficulty inambulating and fell yesterday. When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation?

Options

  • AComplaints of a headache
  • BLoss of superficial and deep tendon reflexes
  • CComplaints of shortness of breath
  • DFacial paralysis

Explanation

(A) Headaches are not associated with Guillain-Barr?syndrome. (B) Loss of superficial and deep tendon reflexes is expected with this diagnosis. (C) Complaints of shortness of breath must be further evaluated. Forty percent of all clients have some detectable respiratory weakness and should be prepared for a possible tracheostomy. Pneumonia is also a common complication of this syndrome. (D) Facial paralysis is expected and is not considered abnormal.

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