While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse? A. Lower leg weakness. B. Full facial flushing. C. Irregular heart rate. D. Profuse diaphoresis.
The correct answer and explanation is:
The correct answer is C. Irregular heart rate.
Guillain-Barré Syndrome (GBS) is an autoimmune disorder where the body’s immune system mistakenly attacks the peripheral nervous system, leading to muscle weakness, paralysis, and sometimes autonomic dysfunction. The syndrome often begins with weakness or tingling in the legs and can progress to the upper limbs and, in severe cases, respiratory failure. One of the most concerning complications of GBS is its effect on the autonomic nervous system, which controls involuntary functions such as heart rate and blood pressure.
An irregular heart rate (arrhythmia) is a potentially serious finding in a client with Guillain-Barré syndrome, as it can indicate autonomic dysfunction. This condition can be life-threatening because it may lead to severe cardiac issues like bradycardia (slow heart rate) or tachycardia (fast heart rate), both of which can result in inadequate circulation and oxygen delivery to vital organs. As the autonomic nervous system becomes involved, monitoring for arrhythmias is critical in preventing cardiac arrest or other serious complications.
Lower leg weakness is a common and expected finding in GBS, and while it should still be monitored, it is not as urgent or alarming as an irregular heart rate.
Full facial flushing could be related to autonomic dysfunction, but it is less directly concerning than arrhythmias. Similarly, profuse diaphoresis can also occur with autonomic dysfunction, but it is typically not as immediately dangerous as changes in the heart rate.
Therefore, irregular heart rate is the most urgent finding to report, as it can result in severe consequences if not promptly addressed.