Difficulty: Medium
Average Score: 95%
Simulated
The nurse is caring for a client with a diagnosis of Guillain-Barr├® syndrome (GBS). Which assessment finding is most consistent with this diagnosis?
Correct answer
A
Rationale
Guillain-Barr├® syndrome is characterized by an ascending paralysis that typically begins in the lower extremities and progresses upward, often symmetrically. This is due to demyelination of the peripheral nerves. A sudden severe headache (B) is more indicative of a subarachnoid hemorrhage or migraine. Loss of vision in one eye (C) suggests optic neuritis or a retinal issue. Numbness and tingling in the hands (D) could be carpal tunnel syndrome or peripheral neuropathy, but it lacks the ascending pattern classic to GBS.