# A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing ascending paralysis and respiratory compromise. Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541210 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing ascending paralysis and respiratory compromise. Which nursing intervention should be the highest priority? The patient shows signs of diaphragmatic weakness and decreased vital capacity. ## 보기 1. Administer prescribed corticosteroids to reduce inflammation 2. Perform passive range of motion exercises to prevent contractures 3. Provide emotional support and reassurance to reduce anxiety 4. Monitor respiratory status and prepare for mechanical ventilation **✔ 정답** **정답: 4** ## 해설 In Guillain-Barré syndrome with respiratory compromise, monitoring respiratory status and preparing for mechanical ventilation is the highest priority to prevent life-threatening failure. Other interventions are important but secondary to ensuring adequate ventilation. ## 심화 해설 Clinical Priority in Ascending Paralysis In Guillain-Barré syndrome (GBS), an acute immune-mediated polyradiculoneuropathy, the classic presentation is a symmetric, ascending weakness that can progress to the muscles of respiration. The foundational principle of nursing care for this condition is that GBS is a major cause of neuromuscular respiratory failure globally [1]. As the paralysis ascends, it can involve the diaphragm and intercostal muscles, leading to ineffective ventilation and a life-threatening emergency. Therefore, the highest priority nursing intervention is derived directly from the Airway, Breathing, Circulation (ABC) framework. Why Respiratory Monitoring is the Priority The other listed interventions are all appropriate components of holistic care for a patient with GBS, but they do not address the most immediate threat to life. The primary danger is not a contracture, a deep vein thrombosis, or pain, but rather the insidious onset of respiratory failure. The case reports underscore this reality. One case describes a patient managed in a stepdown unit with close respiratory monitoring, which was the specific intervention that prevented progression to respiratory failure and the need for intensive care unit (ICU) admission [2]. In a resource-limited setting without access to invasive ventilation, a structured framework was built around noninvasive respiratory support and intensive nursing care to manage respiratory failure successfully [1]. These examples demonstrate that vigilant, continuous assessment of respiratory function—including vital capacity, negative inspiratory force, and signs of hypoxia or hypercapnia—is the cornerstone of patient safety. The nurse must be prepared to escalate care and assist with mechanical ventilation the moment clinical indicators show the patient can no longer protect their own airway or ventilate adequately. Integrating the Evidence into Practice For the NCLEX-RN examinee, this question highlights the critical distinction between a routine intervention and a life-saving priority. While performing passive range of motion exercises, monitoring for deep vein thrombosis, and managing pain are all within the nurse's scope for a patient with immobility and neuropathic discomfort, they are secondary to ensuring the patient is breathing. The evidence confirms that even in a case where a patient did not ultimately require ICU admission, the decision to provide close respiratory monitoring was the key safety net [2]. The nurse’s clinical judgment must focus on the predictable trajectory of ascending paralysis: what begins as leg weakness can rapidly become diaphragmatic weakness. A systematic assessment of respiratory rate, depth, breath sounds, and the patient’s ability to cough and clear secretions provides the data necessary to prevent respiratory arrest, which is the most catastrophic outcome of GBS.References (research sources) - [1]High-Dependency Care Without Mechanical Ventilation for Severe Guillain-Barré Syndrome in a Rural Low-Income Setting.Research articleNotghi L, Little L, Chin J. (2026) · DOI: 10.1155/crcc/1700879 - [2]Guillain-Barré Syndrome Following Seasonal Coronavirus (HCoV-229E) Infection: A Case Managed Without Intensive Care.Case reportWeldearegay G, Aghabekyan T, Arif A, Salvani J. (2026) · DOI: 10.7759/cureus.107360 ## 임상 시나리오 Clinical Priority: Impending Respiratory Failure in Guillain-Barré Syndrome A patient with Guillain-Barré syndrome (GBS) and ascending paralysis is exhibiting diaphragmatic weakness and a declining vital capacity. The immediate clinical priority is to prevent neuromuscular respiratory failure, the most common cause of death in GBS. The nurse must implement continuous respiratory monitoring and prepare for airway management. Key Clinical Indicators for Intervention - **Vital Capacity:** A drop below 15-20 mL/kg or a rapid decline of more than 30% is a strong predictor of impending respiratory failure and the need for intubation. - **Negative Inspiratory Force (NIF):** A NIF less than -20 to -30 cm H2O indicates severe inspiratory muscle weakness. - **Clinical Signs:** Monitor for use of accessory muscles, staccato speech, inability to count to 20 in a single breath, and paradoxical abdominal breathing. - **Blood Gases:** Serial arterial blood gas (ABG) monitoring will show rising PaCO2 (hypercapnia) as a late sign of hypoventilation. Nursing Actions and Rationale - **Continuous Monitoring:** Place the patient on continuous pulse oximetry and capnography if available. Perform bedside pulmonary function tests (vital capacity, NIF) every 1-4 hours during the progressive phase. - **Prepare for Intubation:** Have emergency airway equipment (bag-valve mask, endotracheal tube, suction) at the bedside. Notify the rapid response team and intensivist early; elective intubation is preferred over emergent intubation. - **Medication Review:** Hold or avoid sedatives and neuromuscular blocking agents that can further compromise respiratory drive. Note that corticosteroids are not recommended in GBS; standard disease-modifying therapies are intravenous immunoglobulin (IVIG) or plasmapheresis. - **Positioning:** Elevate the head of the bed to reduce the work of breathing and optimize diaphragmatic excursion, unless contraindicated. By prioritizing respiratory assessment and proactive preparation for mechanical ventilation, the nurse directly addresses the most life-threatening risk in GBS, aligning with the ABC (Airway, Breathing, Circulation) framework. ## 핵심 개념 - **Guillain-Barré Syndrome** — Acute autoimmune demyelinating polyneuropathy. Damage to the myelin sheath of peripheral nerves causes paralysis and sensory abnormalities that start in the lower limbs and ascend. - **Ascending Paralysis** — Paralysis that starts in the lower extremities and gradually spreads upward to the trunk, upper extremities, face, and respiratory muscles. This is a typical symptom of GBS. - **Vital Capacity** — The maximum amount of air that can be forcefully exhaled after a full inhalation. It is an important indicator for assessing respiratory muscle strength and is used to determine the risk of respiratory failure in GBS patients. - **Diaphragmatic Weakness** — Decreased function of the diaphragm, the primary respiratory muscle. This reduces breathing efficiency and makes abdominal breathing difficult, which can lead to respiratory failure. - **Mechanical Ventilation** — A treatment that artificially delivers air into the lungs to maintain ventilation when the respiratory muscles fail to function properly. 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