Difficulty: Medium
Average Score: 95%
Full-length
The nurse is caring for a client with Guillain-Barr├â┬® syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?
Correct answer
C
Rationale
Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barr├â┬® syndrome, making it the priority.