Which Assessment Data for a Patient Who Has Guillain-Barré Syndrome

Multiple Choice

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.