Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action?
a. The patient's triceps reflexes are absent.
b. The patient is continuously drooling saliva.
c. The patient complains of severe pain in the feet.
d. The patient's blood pressure (BP) is 150/82 mm Hg.
ANS: B
Drooling indicates decreased ability to swallow, which places the patient 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.
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