The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?
A)The client has continuous drooling of saliva.
B)The client's blood pressure (BP) is 106/50 mm Hg.
C)The client's quadriceps and triceps reflexes are absent.
D)The client complains of severe tingling pain in the feet.

Question

Quizplus · Accepted Answer

Drooling indicates decreased ability to swallow, which places the client at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

The Nurse Is Caring for a Client Who Has Guillain-Barré