A 27-year-old patient is hospitalized with new onset of Guillain-Barré syndrome. The most essential assessment for the nurse to carry out is
a. determining level of consciousness.
b. checking strength of the extremities.
c. observing respiratory rate and effort.
d. monitoring the cardiac rate and rhythm.
ANS: C
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.
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