The Nurse Is Caring for a Client Who Has Guillain-Barré

question 2

Multiple Choice

The nurse is caring for a client who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?

• A)The client has continuous drooling of saliva.
• B)The client's blood pressure (BP) is 106/50 mm Hg.
• C)The client's quadriceps and triceps reflexes are absent.
• D)The client complains of severe tingling pain in the feet.