# Situation: A 38-year-old man is admitted to the neurology ward with Guillain-Barré syndrome (GBS). Leg weakness began 4 days ago and is spreading upward. He had diarrhea 2 weeks before. He weighs 70 kg and has no other illness. The nurse plans his care for the first 72 hours. Which interventions should be included? 1. Measure vital capacity and negative inspiratory force as ordered 2. Prepare to give intravenous methylprednisolone daily 3. Turn him every 2 hours and off-load his heels 4. Apply intermittent pneumatic compression devices

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630429  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 38-year-old man is admitted to the neurology ward with Guillain-Barré syndrome (GBS). Leg weakness began 4 days ago and is spreading upward. He had diarrhea 2 weeks before. He weighs 70 kg and has no other illness.

The nurse plans his care for the first 72 hours. Which interventions should be included?
1. Measure vital capacity and negative inspiratory force as ordered
2. Prepare to give intravenous methylprednisolone daily
3. Turn him every 2 hours and off-load his heels
4. Apply intermittent pneumatic compression devices

## 보기

1. 1 and 3
2. 1, 3 and 4 **✔ 정답**
3. 2, 3 and 4
4. 1, 2 and 4

**정답: 2**

## 해설

Respiratory monitoring with vital capacity and negative inspiratory force is the top priority because weakness can ascend to the respiratory muscles. Immobility brings a high risk of pressure injury and venous thromboembolism, so turning, heel off-loading, and compression devices are included. Corticosteroids are not effective in Guillain-Barré syndrome; immunoglobulin or plasma exchange is used.

## 심화 해설

Priorities in the first 72 hours
Guillain-Barré syndrome (GBS) produces weakness that can keep ascending for days to weeks. The early nursing plan therefore centers on three threats: respiratory failure, pressure injury, and venous thromboembolism (VTE). The correct set is statements 1, 3 and 4: measuring vital capacity and negative inspiratory force, turning every 2 hours with heel off-loading, and applying intermittent pneumatic compression. Respiratory monitoring is the top priority because ascending weakness can reach the diaphragm and intercostal muscles.

Respiratory monitoring
Vital capacity and negative inspiratory force measure the strength of the breathing muscles and fall before oxygen saturation drops. Pulse oximetry can stay normal until late, so it is not a reliable early warning in neuromuscular weakness. Serial measurements as ordered show the trend, and a falling value prompts the team to plan elective intubation before a crisis. The nurse also watches for a weak cough, difficulty swallowing, and a soft voice, which signal risk to the airway.

Immobility: skin and clots
A client who cannot move his legs lies still for long periods, which loads the sacrum and heels and slows venous return. Turning every 2 hours and floating the heels off the mattress relieve pressure on bony prominences. Intermittent pneumatic compression devices mimic the calf muscle pump and reduce stasis in the deep veins. Immobility in GBS carries a high risk of venous thromboembolism, so mechanical prophylaxis belongs in the plan, often together with prescribed pharmacologic prophylaxis.

Why corticosteroids are excluded
Statement 2 is the trap. Although GBS is immune-mediated, trials have shown that corticosteroids are not effective in GBS, and they are not part of standard treatment. The disease-modifying treatments are intravenous immunoglobulin (IVIG) and plasma exchange, which shorten the course when started early. Any option containing methylprednisolone is therefore wrong. Option 1 (1 and 3) omits compression devices; options 3 and 4 include corticosteroids and also leave out respiratory monitoring or turning.

| Statement | Include? | Reason |
| --- | --- | --- |
| 1. Vital capacity and NIF | Yes | Detects respiratory muscle weakness early |
| 2. IV methylprednisolone | No | Corticosteroids are not effective in GBS |
| 3. Turning and heel off-loading | Yes | Prevents pressure injury |
| 4. Pneumatic compression | Yes | Prevents venous thromboembolism |

Key point! In GBS, plan for breathing, skin, and clots. Treatment is immunoglobulin or plasma exchange, never corticosteroids alone.

## 임상 시나리오

Early Care Plan in GBSBreathing, skin and clot prevention
Ascending weakness can reach the breathing muscles, so the nurse measures vital capacity and negative inspiratory force as ordered; these fall before oxygen saturation does.

Immobility threatens the skin and veins. Turning every 2 hours, floating the heels, and intermittent pneumatic compression protect against pressure injury and venous thromboembolism.

Disease-modifying treatment is intravenous immunoglobulin or plasma exchange; corticosteroids are not effective in GBS.

CautionDo not rely on pulse oximetry alone; a normal SpO2 can hide a falling vital capacity until respiratory failure is close.

## 핵심 개념

- **Vital capacity** — The maximum volume of air a person can exhale after a maximal inhalation, used to track breathing muscle strength.
- **Negative inspiratory force** — The greatest negative pressure a client can generate on inspiration, a bedside measure of diaphragm strength.
- **Intermittent pneumatic compression** — Inflatable leg sleeves that squeeze the calves in cycles to promote venous return and prevent deep vein thrombosis.
- **Plasma exchange** — Removal of the client's plasma, with its antibodies, and replacement with albumin or plasma; a treatment for Guillain-Barré syndrome.

## 같은 주제 문제

- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630316)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630317)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630318)
- [Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in t…](https://mymerci.kr/pages/nclex_q.php?qn_id=630319)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630320)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630321)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630322)
- [Situation: A 72-year-old woman with Parkinson disease for 9 years is admitted to the medic…](https://mymerci.kr/pages/nclex_q.php?qn_id=630323)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._