# 一位因格林-巴利症候群入院的個案，無力情形已從雙腿進展到雙臂。護理師現在注意到個案咳嗽無力、呼吸淺快，且難以一口氣說完一個完整句子。護理師應優先採取哪項行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=zh-tw > language: zh-TW > subject: Medical Emergencies > category: PA ## 題目 一位因格林-巴利症候群入院的個案，無力情形已從雙腿進展到雙臂。護理師現在注意到個案咳嗽無力、呼吸淺快，且難以一口氣說完一個完整句子。護理師應優先採取哪項行動？ ## 選項 1. 協助個案行走，以利呼吸道分泌物開始排出 2. 提供口服液體以稀釋分泌物，並在個案休息後重新評估 3. 在雙腿放置溫熱敷布，以減緩上行性無力 4. 緊急評估呼吸功能，並準備呼吸器支持 **✔ 正確答案** **正確答案: 4** ## 解析 格林-巴利症候群可能快速使呼吸肌無力。咳嗽無力、呼吸淺快及無法說完一個完整句子，表示即將發生呼吸衰竭，因此緊急呼吸評估及準備呼吸器支持為優先。 ## 深入解析 快速解答 緊急評估呼吸能力並準備呼吸器支持。無力正影響到呼吸肌。 為什麼這是正確的 上行性周邊神經無力可能在血氧飽和度改變前就損害橫膈膜及呼吸道清除能力。新出現的咳嗽及說話表現是床邊警訊，需要密切的呼吸測量及快速升級處置。 簡單比喻或心智圖像 無力就像爬樓梯，正朝向負責呼吸的肌肉前進。護理師必須在它到達頂端前做好準備，但此比喻不能取代連續的呼吸測量或個別化的呼吸道決策。 記憶掛鉤 上行性無力加上咳嗽無力，意味著呼吸衰竭可能接踵而至。 NCLEX 決策規則 在進行性神經肌肉疾病中，當咳嗽力量、說話或呼吸深度惡化時，優先考慮通氣支持。不要等到晚期低血氧才升級呼吸道支持。 為什麼其他選項是錯的 行走不安全且增加需求。口服液體無法矯正呼吸肌無力，而溫熱敷布無法減緩免疫媒介的神經功能障礙。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NINDS: Guillain-Barre SyndromeNational Institute of Neurological Disorders and Stroke ## 相同主題題目 - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=zh-tw) - [A 68-year-old client with COPD is admitted with shortness of breath and SpO2 86% on room a…](https://mymerci.kr/pages/nclex_q.php?qn_id=362940&lang=zh-tw) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=zh-tw) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=zh-tw) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=zh-tw) - [A nurse is caring for a client prescribed Digoxin. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=zh-tw) - [A nurse is caring for a client prescribed Lithium. Which nursing action is most appropriat…](https://mymerci.kr/pages/nclex_q.php?qn_id=375233&lang=zh-tw) - [A nurse is caring for a client prescribed Spironolactone. Which nursing action is most app…](https://mymerci.kr/pages/nclex_q.php?qn_id=391869&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498728&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_