A client admitted with Guillain-Barre syndrome has weakness that has progressed from the legs to the arms. The nurse now notes a weak cough, shallow respirations, and difficulty counting through a full sentence. Which action should the nurse take first?
1Assist the client to walk so respiratory secretions begin to mobilize
2Offer oral fluids to loosen secretions and reassess after the client rests
3Place warm compresses on the legs to slow the ascending weakness
4Assess respiratory function urgently and prepare for ventilatory support✓ Correct answer
Explanation
Guillain-Barre syndrome can rapidly weaken respiratory muscles. A weak cough, shallow breathing, and inability to speak a full sentence indicate impending respiratory failure, so urgent respiratory assessment and preparation for ventilatory support take priority.
Quick answer Urgently assess breathing capacity and prepare ventilatory support. The weakness is reaching the respiratory muscles.
Why this is correct Ascending peripheral nerve weakness can impair the diaphragm and airway clearance before oxygen saturation changes. The new cough and speech findings are bedside warning signs that require close respiratory measurement and rapid escalation.
Easy analogy or mental picture The weakness is climbing a staircase toward the muscles that power breathing. The nurse must prepare before it reaches the top, but the analogy does not replace serial respiratory measurements or individualized airway decisions.
Memory hook Ascending weakness plus a weak cough means breathing failure may be next.
NCLEX decision rule In a progressive neuromuscular disorder, prioritize ventilation when cough strength, speech, or respiratory depth worsens. Do not wait for late hypoxemia before escalating airway support.
Why the other choices are wrong Walking is unsafe and increases demand. Oral fluids do not correct respiratory muscle weakness, and warm compresses do not slow immune-mediated nerve dysfunction.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
NINDS: Guillain-Barre SyndromeNational Institute of Neurological Disorders and Stroke