# A nurse is caring for a client with Guillain-Barré syndrome who is experiencing ascending paralysis. Which assessment finding requires the most immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541215 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with Guillain-Barré syndrome who is experiencing ascending paralysis. Which assessment finding requires the most immediate nursing intervention? ## 보기 1. Decreased vital capacity and shallow respirations **✔ 정답** 2. Numbness and tingling in the lower extremities 3. Difficulty swallowing and mild dysarthria 4. Muscle weakness in bilateral upper extremities **정답: 1** ## 해설 Decreased vital capacity and shallow respirations indicate imminent respiratory failure, requiring immediate intervention. Other findings are expected in GBS but do not pose an immediate life-threatening risk. ## 심화 해설 Clinical Reasoning and Priority Setting The correct answer is Decreased vital capacity and shallow respirations. In Guillain-Barré syndrome (GBS), the hallmark of clinical deterioration is ascending paralysis that can progress to involve the respiratory muscles. When applying the nursing process and prioritizing client needs, the airway, breathing, and circulation (ABC) framework always takes precedence. A decrease in vital capacity and the presence of shallow respirations are direct indicators of impending respiratory failure, the most life-threatening complication of GBS. Pathophysiology and Clinical Correlation GBS is an acute, immune-mediated polyneuropathy characterized by demyelination and axonal degeneration of peripheral nerves. The ascending paralysis pattern means weakness typically begins in the lower extremities and moves upward. The critical danger occurs when this paralysis reaches the diaphragm and intercostal muscles. The assessment findings in option 1 signify that the neuromuscular blockade is compromising the mechanics of ventilation. A falling vital capacity reflects weakening of the diaphragm, and shallow respirations indicate that the tidal volume is becoming insufficient to maintain effective gas exchange. This trajectory leads directly to hypercapnia, hypoxemia, and respiratory arrest if not immediately managed with ventilatory support. The urgency of this finding is strongly supported by the provided evidence. A case report by Penfold et al. highlights a patient with a GBS variant who developed bilateral vocal cord paralysis and subsequent respiratory failure, ultimately requiring emergency intubation and tracheostomy [1]. This underscores how rapidly bulbar and respiratory muscle involvement can necessitate definitive airway management. Furthermore, a retrospective study by Surve et al. on pediatric GBS patients in the intensive care unit identifies the need for mechanical ventilation as a primary outcome, emphasizing that recognizing the clinical predictors of intubation is a central concern in acute GBS management [2]. These sources confirm that monitoring for and responding to respiratory decompensation is the highest nursing priority. Analysis of Other Options - Option 2: Numbness and tingling in the lower extremities. These are classic early sensory symptoms of GBS. While important to document and monitor, they represent the initial phase of the disease process and do not pose an immediate threat to the client's survival. They are a lower priority than a compromised airway and breathing. - Option 3: Difficulty swallowing and mild dysarthria. These findings indicate bulbar muscle involvement, which is a serious progression of GBS. Dysphagia increases the risk of aspiration, and dysarthria signals weakness in the muscles controlling speech. This finding requires prompt intervention, such as placing the client on NPO status and elevating the head of the bed. However, it is secondary to the immediate life threat of respiratory muscle failure. Airway protection is a concern, but ventilatory failure is a more imminent cause of death. - Option 4: Muscle weakness in bilateral upper extremities. This is a sign of the ascending paralysis reaching the upper limbs. While it represents disease progression and impacts the client's functional ability, it does not directly threaten the airway or breathing. It is a lower priority than respiratory assessment findings. Essential Nursing Action The most immediate nursing intervention for a client with a decreasing vital capacity is to prepare for emergency airway management. This involves positioning the client to optimize breathing, providing supplemental oxygen, having emergency intubation equipment at the bedside, and immediately notifying the rapid response team and the healthcare provider. Continuous monitoring of oxygen saturation, end-tidal CO2 if available, and serial vital capacity measurements are critical to determine the exact moment when non-invasive support must transition to mechanical ventilation.References (research sources) - [1]Vocal cord immobility in Guillain-Barré syndrome: a diagnostic challenge.Research articlePenfold A, Haymes A, Evans-Tomlinson A, Karagama Y. (2026) · DOI: 10.1136/bcr-2026-273061 - [2]Clinical predictors of intubation and prolonged ventilation in pediatric Guillain-Barré syndrome requiring intensive care: A retrospective observational study.Research articleSurve RM, Sharma P, Chakrabarti D, Nisal R, Raghavendra K, Kulkarni GB, Kamath S. (2026) · DOI: 10.1016/j.braindev.2026.104549 ## 임상 시나리오 Guillain-Barré Syndrome: Respiratory MonitoringPrioritizing ABCs in Ascending Paralysis Monitor vital capacity and respiratory effort frequently. A decline in vital capacity to below 15-20 mL/kg or the presence of shallow respirations signals impending respiratory failure. Even with stable oxygen saturation, a falling vital capacity indicates weakening of the diaphragm and intercostal muscles, requiring preparation for mechanical ventilation. CautionDo not rely solely on pulse oximetry; hypercapnia from hypoventilation precedes hypoxemia. Bulbar dysfunction with dysphagia increases aspiration risk but is secondary to the priority of maintaining ventilation. ## 핵심 개념 - **Vital capacity** — The maximum amount of air a person can expel from the lungs after a maximum inhalation; a falling vital capacity indicates weakening respiratory muscles. - **Ascending paralysis** — A pattern of muscle weakness that begins in the lower extremities and moves upward, characteristic of Guillain-Barré syndrome. - **Guillain-Barré syndrome (GBS)** — An acute, immune-mediated polyneuropathy causing demyelination and axonal degeneration of peripheral nerves, often leading to progressive weakness. - **ABC framework** — A priority-setting model in nursing that ranks Airway, Breathing, and Circulation as the most critical needs to address first. - **Respiratory failure** — A life-threatening condition where the respiratory system fails in oxygenation or carbon dioxide elimination, a primary risk in severe GBS. ## 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 45-year-old patient with Guillain-Barré syndrome who reports weakn…](https://mymerci.kr/pages/nclex_q.php?qn_id=541212) - [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) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._