A nurse is educating a client who has Guillain-Barré syndrome (GBS). The client says to the nurse, "I don't understand why I have this condition." How should the nurse respond?

Choice A reason:

This is a correct answer. The nurse should explain to the client that GBS is an autoimmune disorder that causes inflammation and demyelination of the peripheral nerves, which can affect sensation, movement, and autonomic function. GBS occurs when the immune system mistakenly attacks the peripheral nerves, often after an infection or vaccination.

Choice B reason:

This is an incorrect answer. The nurse should not tell the client that they have GBS because their body produces antibodies against their myelin sheath. This is not the mechanism of GBS, but rather multiple sclerosis (MS), which is another autoimmune disorder that causes inflammation and demyelination of the central nervous system (CNS).

Choice C reason:

This is an incorrect answer. The nurse should not tell the client that they have GBS because they have a genetic mutation that affects their nerve function. This is not the cause of GBS, but rather Charcot-Marie-Tooth disease (CMT), which is a hereditary disorder that affects the structure and function of the peripheral nerves.

Choice D reason:

This is an incorrect answer. The nurse should not tell the client that they have GBS because they have been exposed to a virus that infects their nerve cells. This is not the cause of GBS, but rather encephalitis, which is an acute inflammatory condition of the brain that can be caused by various viruses or bacteria.

Choice A reason:

This is an incorrect answer. Administering analgesics and antiemetics as prescribed is not an effective intervention to relieve the client's symptoms of headache, nausea, and vomiting due to meningitis. Analgesics and antiemetics can have adverse effects such as sedation, hypotension, or constipation, which can worsen the client's condition or mask signs of increased intracranial pressure (ICP). The nurse should use non-pharmacological methods to relieve the client's symptoms and monitor their vital signs and neurological status.

Choice B reason:

This is an incorrect answer. Elevating the head of the bed to 45 degrees is not an effective intervention to relieve the client's symptoms of headache, nausea, and vomiting due to meningitis. Elevating the head of the bed can increase ICP by reducing venous drainage from the brain, which can worsen the client's condition or cause complications such as herniation or hydrocephalus. The nurse should keep the head of the bed flat or slightly elevated and avoid neck flexion or rotation.

Choice C reason:

This is an incorrect answer. Applying a cold compress to the forehead is not an effective intervention to relieve the client's symptoms of headache, nausea, and vomiting due to meningitis. A cold compress can cause vasoconstriction and reduce blood flow and oxygen delivery to the brain, which can worsen the client's condition or cause ischemia or infarction. The nurse should avoid applying cold or heat to the head and maintain a normal body temperature for the client.

Choice D reason:

This is a correct answer. Dimming the lights and reducing noise in the room is an effective intervention to relieve the client's symptoms of headache, nausea, and vomiting due to meningitis. Dimming the lights and reducing noise can decrease sensory stimulation and irritation of the optic nerve or cranial nerves that control the pupillary reflex by the inflamed meninges. The nurse should also provide a quiet and calm environment for the client and limit visitors and activities.