# A nurse is caring for a 45-year-old patient with Guillain-Barré syndrome who reports weakness that began in the feet and has progressively moved upward to the thighs over the past 2 days, indicating ascending paralysis. Which nursing action should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541212 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 45-year-old patient with Guillain-Barré syndrome who reports weakness that began in the feet and has progressively moved upward to the thighs over the past 2 days, indicating ascending paralysis. Which nursing action should be the highest priority? A 45-year-old patient with Guillain-Barré syndrome is admitted to the medical unit. The patient reports weakness that began in the feet and has progressively moved upward to the thighs over the past 2 days. ## 보기 1. Administer prescribed pain medication for neuropathic pain 2. Monitor respiratory status and prepare for potential mechanical ventilation **✔ 정답** 3. Perform passive range of motion exercises to prevent contractures 4. Assess deep tendon reflexes and document neurological changes **정답: 2** ## 해설 In Guillain-Barré syndrome with ascending paralysis, respiratory compromise is the most life-threatening complication, requiring priority monitoring and preparation for ventilation. Other options manage pain, prevent contractures, or assess reflexes but are secondary to respiratory care. ## 심화 해설 Understanding the Priority in Guillain-Barré Syndrome The patient's presentation of ascending paralysis, which has progressed from the feet to the thighs over two days, is a classic hallmark of Guillain-Barré syndrome (GBS). In GBS, the immune system mistakenly attacks the peripheral nerves' myelin sheath, leading to a rapidly progressive, symmetrical weakness. The most critical and life-threatening complication of this ascending pattern is its potential to involve the muscles of respiration, leading to neuromuscular respiratory failure. This is a major cause of morbidity and mortality in GBS globally [1]. Therefore, the highest priority nursing action must focus on anticipating and managing this risk. Why Respiratory Monitoring is the Priority While pain management, range of motion exercises, and neurological assessments are all important components of care, they are secondary to ensuring a patent airway and adequate ventilation. The pathophysiological basis for this priority lies in the progression of demyelination. As the immune-mediated damage ascends, it can impair the phrenic nerve, which innervates the diaphragm, and the intercostal nerves, which supply the muscles between the ribs. This results in a restrictive ventilatory defect. A patient who reports weakness reaching the thighs is at high risk for imminent respiratory compromise, as the next areas to be affected can be the trunk and chest wall. The provided case reports consistently underscore that even in settings without immediate access to an intensive care unit (ICU), the core of management is structured, close respiratory monitoring. One case explicitly details managing severe GBS with bulbar weakness using a high-dependency unit framework that combined noninvasive respiratory support with intensive nursing care, successfully avoiding the need for invasive ventilation [1]. Another report highlights a patient who was managed with intravenous immunoglobulin (IVIG) and "close respiratory monitoring in a stepdown unit without progression to respiratory failure or need for intensive care unit (ICU) admission" [2]. These examples demonstrate that vigilant monitoring is the decisive factor in preventing a respiratory crisis. The other options, while clinically relevant, are not the immediate priority for a patient with active, ascending weakness: - Administering pain medication for neuropathic pain is a comfort measure but does not address a life-threatening complication. - Performing passive range of motion exercises is crucial for preventing long-term contractures but is not an urgent, life-saving intervention. - Assessing deep tendon reflexes and documenting neurological changes is a key part of the ongoing assessment. However, in the context of a known, rapidly ascending paralysis, the assessment that takes absolute precedence is the one that detects a failure in airway, breathing, or ventilation. The classic GBS presentation includes symmetrical weakness and areflexia , and while documenting this is necessary, it does not supersede the immediate need to prepare for potential respiratory failure, a well-documented outcome of the disease process .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 Guillain-Barré Syndrome: Respiratory PriorityManaging the Risk of Ascending Paralysis The highest priority in ascending paralysis is continuous monitoring of respiratory status. Paralysis can progress to the trunk and respiratory muscles within hours, leading to neuromuscular respiratory failure, the primary cause of death in GBS. Assess respiratory function using objective measures: forced vital capacity (FVC), negative inspiratory force (NIF), and single breath count. Prepare for mechanical ventilation when FVC drops below 20 mL/kg or NIF is less than -30 cm H2O. CautionDo not rely solely on oxygen saturation or respiratory rate. A patient with impending respiratory failure may maintain normal SpO2 until very late. Deterioration can be rapid; have emergency airway equipment at the bedside at all times. ## 핵심 개념 - **Guillain-Barré syndrome (GBS)** — An acute, immune-mediated polyneuropathy characterized by rapidly progressive, symmetrical ascending paralysis due to demyelination of peripheral nerves. - **Ascending paralysis** — A pattern of weakness that begins in the distal extremities and moves proximally toward the trunk, a classic presentation of GBS that can progress to involve respiratory muscles. - **Neuromuscular respiratory failure** — The most serious complication of GBS, occurring when demyelination affects the phrenic and intercostal nerves, impairing diaphragm and chest wall function. - **Phrenic nerve** — The nerve that originates from C3-C5 and innervates the diaphragm; its dysfunction leads to diaphragmatic paralysis and respiratory compromise. - **Demyelination** — The pathological process in GBS where the immune system attacks and strips the myelin sheath from peripheral nerves, disrupting nerve signal transmission. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old patient with suspected Guillain-Barré syndrome who was …](https://mymerci.kr/pages/nclex_q.php?qn_id=541207) - [A nurse is assessing a 60-year-old patient with suspected Guillain-Barré syndrome who pres…](https://mymerci.kr/pages/nclex_q.php?qn_id=541208) - [A nurse is assessing a 45-year-old patient with suspected Guillain-Barré syndrome who was …](https://mymerci.kr/pages/nclex_q.php?qn_id=541209) - [A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing ascending…](https://mymerci.kr/pages/nclex_q.php?qn_id=541210) - [A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing respirato…](https://mymerci.kr/pages/nclex_q.php?qn_id=541211) - [A nurse is caring for a client with Guillain-Barré syndrome who is experiencing ascending …](https://mymerci.kr/pages/nclex_q.php?qn_id=541213) - [A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing progressi…](https://mymerci.kr/pages/nclex_q.php?qn_id=541214) - [A nurse is caring for a client with Guillain-Barré syndrome who is experiencing ascending …](https://mymerci.kr/pages/nclex_q.php?qn_id=541215) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._